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BISMUTH  PASTE 

IN 

CHRONIC  SUPPURATIONS 


BTSMUTH  PASTE 


IN 


CHRONIC  SUPPURATIONS 


ITS  DIAGNOSTIC  IMPOETANCE  AND 
THEEAPEUTIC  VALUE 


BY 

EMIL  G.  BECK,  M.  D. 

SURGEON   TO  THE   NORTH   CHICAGO   HOSPITAL,   CHICAGO,    ILL. 

With  an  Introduction  by  Carl  Beck,  M.  D. 

and  a 

Chapter  on  the  Application  of  Bismuth  Paste  in  the  Treatment  of 

Chronic  Suppuration  of  the  Nasal  Accessory  Sinuses 

and  the  Ear,  by  Joseph  C.  Beck,  M.  D. 


With  Eighty-One  Engravings,  Nine  Diagrammatic 
Illustrations,  and  a  Colored  Plate. 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1914 


Copyright,  1910,  by  C.  V.  Mosby  Company 


„    is 


■   Press  of 

C.  V.  Mosby  Company 

St.  Louis 


DEDICATED  TO 

CLARA  BECK 

MY  WIFE 


PREFACE. 

During  the  past  year  a  number  of  my  confreres  have 
advised  me  to  write  a  monograph  on  the  uses  of  bismuth 
paste,  believing  that  the  subject  was  of  vital  importance 
and  that  the  general  practitioner  was  not  sufficiently 
familiar  with  the  method  to  apply  it  to  the  best  advan- 
tage. My  reluctance  has  rested  on  the  belief  that  the 
subject  was  yet  immature  for  such  publication,  but,  yield- 
ing to  persistent  urging  from  various  sources,  I  am 
prompted  to  bring  forth  the  subject  in  its  present  state 
of  development  in  the  hope  that  in  the  meantime  many 
may  benefit  by  the  experience  thus  far  acquired  in  treat- 
ing a  large  variety  of  cases  by  this  new  method. 

Judging  from  the  number  of  inquiries  we  have  received 
from  surgeons  and  physicians,  as  well  as  from  special- 
ists, I  must  conclude  that  the  profession  is  sufficiently 
interested  in  this  work  to  receive  it  at  this  time  as  a 
necessary  aid  to  its  proper  and  successful  application. 

I  desire  here  to  acknowledge  the  valuable  aid  received 
from  my  brothers,  Dr.  Carl  Beck  and  Dr.  Joseph  C.  Beck, 
whose  suggestions  have  added  a  great  deal  to  the  develop- 
ment of  this  new  method  of  treating  chronic  suppurative 
diseases. 

No  less  do  I  appreciate  the  service  rendered  to  the 
profession  by  Drs.  Ochsner  and  Mayo,  who  in  their  daily 
clinics  have  spread  the  knowledge  of  this  new  method  of 
treatment  among  a  large  number  of  the  most  active  men 
in  our  profession. 

9 


10  PREFACE. 

I  wish  also  to  express  my  thanks  to  Drs.  J.  Ospray  and 
F.  Turley,  as  well  as  to  Mr.  W.  F.  Willis,  for  their  assist- 
ance in  executing  the  radiographic  work  and  preparing 
the  illustrations. 

The  publishers  have  executed  their  part  of  the  work 
with  promptness  and  exactness,  for  which  I  desire  to  ex- 
press my  appreciation. 

Emil  G.  Beck. 


CONTENTS. 


PAGE 

CHAPTER  I. 

Introduction — By  Carl  Beck,  M.  D.  (Chicago) 17 

CHAPTER  II. 
General  Consideration 21 

(                                 CHAPTER  III. 
Bismuth  Paste  in  Anatomical  Diagnosis 28 

CHAPTER  IV. 
Diagnostic  Errors  Revealed  by  Bismuth  Paste  Injections     ...     35 

CHAPTER  V. 
Therapeutic  Effects  of  Bismuth  Paste 44 

CHAPTER  VI. 
Treatment  of  Sinuses  Due  to  Spondylitis 60 

CHAPTER  VII. 

Treatment  of  Sinuses   Following  Osteomyelitis   and   Joint  Dis- 
eases       69 

CHAPTER  VIII. 

Post-Operative  Sinuses  Following  Abdominal  and  Kidney  Opera- 
tions      110 

CHAPTER  IX. 
Rectal  Fistulae — Diagnosis  and  Treatment  with  Bismuth  Paste  124 

CHAPTER  X. 
Bismuth  Paste  in  Fecal  Fistulae 132 

CHAPTER  XI. 
Bismuth  Paste  Treatment  of  Empyema  and  Lung  Abscess     .     .     .  135 

CHAPTER  XII. 
Bismuth  Paste  in  the  Conservative  Treatment  of  Cold  Abscesses  154 

11 


12  CONTENTS. 

PAGE 

CHAPTER  XIII. 
Limitations  and  Causes  of  Failure 171 

CHAPTER  XIV. 
Bismuth  Poisoning  and  Its  Prevention 180 

CHAPTER  XV. 

Bismuth  Paste  in  the  Treatment  of  Chronic  Suppurative  Dis- 
eases of  the  Nose,  Accessory  Sinuses,  Ears,  and  Mastoid 
Process 199 

CHAPTER  XVI. 
The  Use  of  Bismuth  Paste  in  Dentistry 218 


ILLUSTRATIONS. 


Colored  Plate.    Sequestrum  of  ulna — Reproduced  from  specimens  in 

natural  colors Frontispiece 

FIGURE  PAGE 

1.  Types  of  syringes  used  for  bismuth  paste  injections     ....  29 

2.  Sinus  after  psoas  abscess 30 

3.  Network  of  sinuses  following  tuberculosis  of  iliac  bone    ...  33 

4.  Bronchial  tree  of  a  cat  injected  with  bismuth  paste  to  show 

that  the  smallest  channels  can  be  reached 34 

5.  Osteomyelitis  of  femur,  mistaken  for  hip  joint  disease     ...  35 

6.  Tuberculous  sinus  originating  in  the   sacrum,  thought  to   be 

an  abscess  of  hip 36 

7.  Bismuth    paste    remaining   in    focus    of    disease    four    months 

after  closure — Hip  shown  to  be  normal 37 

8.  Tuberculosis  of  sacrum,  mistaken  for  hip  joint  disease     ...  38 

8  A.     Diagrammatic   illustration  of  Pig.    8 39 

9.  Subphrenic  abscess  following  appendicitis,  suspected  of  being 

an  empyema 40 

9  A.     Diagrammatic   illustration  of  Fig.   9 41 

10.  Unsuspected  renal  sinus  diagnosed  by  bismuth  paste  injection  42 
10  A.     Diagrammatic  illustration  of  Pig.  10 43 

11.  Tuberculous  knee  joint,  showing  remnants  of  paste  four  months 

after  closure 45 

12.  Spondylitis  of  the  tenth  dorsal  vertebra,  with  communicating 

sinuses  in  supraclavicular  and  lumbar  region 64 

13.  Spondylitis  of  tenth  vertebra,  showing  course  of  sinus,  opening 

in  lumbar  region  at  point  of  black  dot,  and  then  downward 

course  into  the  pelvis     ......... 65 

14.  Sinus  following  psoas  abscess,  sixteen  years'  duration — Closed 

after  third  injection  of  bismuth  paste 66 

15.  Bilateral  psoas  abscess  without  destruction  of  vertebras — Each 

opening  above  Poupart's  ligaments 67 

16.  Sinuses  from  nontuberculous  osteomyelitis 70 

17.  Radiograph  of  humerus,  showing  sequestra 72 

17  A.     Diagrammatic  illustration  of  Pig.  17 73 

18.  Three  of  the  sequestra  removed  from  humerus 73 

19.  Bismuth   paste   injected   into   cavity  after   sequestra  were   re- 

moved        74 

19  A.     Diagrammatic  illustration  of  Fig.  19 75 

20.  Bismuth  paste  remaining  after  sinuses  were  closed 76 

21.  Complete  closure  of  sinuses  and  perfect  restoration  of  function 

of  arm 77 

13 


14  ILLUSTRATIONS. 

FIGURE         .  PAGE 

22.  Typhoid  osteomyelitis  of  tibia 78 

23,  24.     Blood  supply  in  bones  of  infant,  showing  subdivisions  of 

nutrient  artery  in  metaphysial  line 80 

25.  Villous  growth  of  tuberculous  knee  joint 83 

26.  Rice  bodies  from  tuberculous  joint 84 

27.  Sinus  openings,  showing  large  pouting  granulations  after  bis- 

muth injections 87 

28.  Radiograph   showing  sinuses  within   hip  after  sixteen   years' 

suppuration — Closure  in  one  month — No  recurrence    ...  90 

29.  Radiograph  showing  path  of  sinus  into  hip  joint     .     .     .     .     .  91 

30.  Hip  joint  disease,  nineteen  years'  duration 92 

31.  Nontuberculous  osteomyelitis  of  femur 94 

32.  Bilateral  tuberculosis — Tibia  in  right  and  femur  in  left  limb 

affected 96 

33.  34.     Radiographs  demonstrating  bilateral  tuberculosis    ....     97 

35.  Demonstration  of  method  of  injection  of  bismuth  paste  into 

sinus  of  the  knee 98 

36.  Tuberculous  knee  joint  with  forty-two  sinuses,  sixteen  years' 

duration 99 

37.  Network  of  sinuses  of  femur 100 

38.  Hopeless     condition    of    old    tuberculous     knee     joint — Bight 

sinuses — Amputation  required 101 

39.  Typical  tuberculous  ankle  joint  with  sinuses 103 

40.  Destruction  of  ankle  joint,  with  ankylosis   (closed)     ....  104 

41.  Tuberculosis  of  os  calcis  injected  with  bismuth  paste     ....  105 

42.  Sinuses  supposed  to  have  originated  from  ribs,  found  to  be  due 

to  tuberculosis  of  sternum 107 

43.  Patient  of  radiograph  shown  in  Fig.  42 — Closure  of  all  sinuses 

after  removal  of  sternal  focus 108 

44.  Sinus  and  fecal  fistula  in  tuberculous  peritonitis Ill 

45.  Sinus  following  tuberculous  peritonitis  after   removal   of  the 

adnexa 116 

46.  Tuberculous  sinuses  of  kidney — Vertebral  column  unaffected    .  120 
46  A.     Diagrammatic  illustration  of  Fig.  46 121 

47.  48.     Patient  with  tuberculous  kidney — Kidney  not  removed     .     .  122 

49.  Rectal  fistula  originating  in  coccyx,  supposed  to  be  of  rectal 

origin 125 

50.  Method  of  injection  of  external  rectal  fistula 127 

51.  Dermoid  cyst  treated  with  bismuth  paste 128 

52.  Supposed  rectal  fistula,   shown  to  be  a  sinus  resulting  from 

disease  of  pelvic  organs 129 

53.  Turtle-shaped  sinus  in  perineal  region,  thought  to  be  a  straight 

rectal  fistula 131 

54.  Method  of  reexpansion  of  lung  by  suction  pump 139 

55.  Cavity  in  pleura  remaining  after  Estlander  operation — Injected 

with  bismuth  paste 141 


ILLUSTRATIONS.  15 

FIGURE  PAGE 

56.  Empyema  of  twenty-eight  years'  duration — Injected  with   bis- 

muth paste — Closure  in  sixty  days 143 

57.  Rubber    coil   showing   against  exposed    pleura,    demonstrating 

relation  to  lung  abscess 148 

58.  Lung  abscess  cavity,  viewed  with  stereoscope,  will  show  four 

bronchial  openings 149 

59.  Multilocular  lung  abscess  injected  with  bismuth  paste     .     .     .  150 
59  A.     Diagrammatic  illustration  of  Fig.  59 151 

60.  Bronchial    tree    injected    with    bismuth    paste    for    anatomical 

study 152 

61.  Psoas  abscess,  pointing  in  the  lumbar  region — Ready  for  spon- 

taneous rupture 159 

62.  Abscess  of  hip  joint  injected  with  bismuth   paste  to   prevent 

sinus 161 

63.  Normal  pelvis  of  same  age,  for  comparison  with  Fig.  62     .     .     .  162 

64.  Patient  whose  pelvis  is  shown  in  Fig.  62,  standing  on  the  dis- 

eased limb  two  weeks  after  injection  of  abscess 163 

65.  Tuberculous  elbow  joint  with  three  abscesses  before  injection 

treatment 164 

66.  Reduction  in  size  of  arm  shown  in  Fig.  65  after  prophylactic, 

conservative  treatment — Secondary  infection  avoided     .     .164 

67.  Radiograph  showing  the  three  distinct  cavities  communicating 

with  the  elbow  joint 166 

67  A.     Diagrammatic  illustration  of  Fig.  67     .     . 167 

68.  69.     Tip  of  probe  within  the  shaft  of  humerus  as  a  cause  of 

failure  of  bismuth   injections — Cavity  filled  with  bismuth 
paste  after  removal  of  foreign  body 173 

70.  Sequestrum   of    the   ulna,    requiring    removal   before    bismuth 

injection 175 

71.  Complete    closure    three   weeks   after    operation    and    bismuth 

treatment — Removal  of  ulna  from  left  arm 176 

72.  Incomplete  injection  of  abscess  cavity,  demonstrating  cause  of 

failure  of  bismuth  treatment  .     .     .     .     : 177 

73.  Injection  of  empyema  after  Estlander  operation  has  failed  to 

obliterate  the  cavity 178 

74.  Photomicrograph  of  section  of  liver  ahout  four  micra  thick — 

In  the  center  of  an  interlobular  vein,  to  the  right  and  above 

a  sublobular  vein — The  intima  of  both  lined  with  bismuth   .  191 

75.  Large  quantities  of  bismuth  paste  retained  in  pelvis,  causing 

absorption — Complete    recovery    after    washing    out    with 

olive  oil 194 

75  A.     Diagrammatic  illustration  of  Fig.  75 195 

76.  Empyema  filled  with  bismuth  paste,  causing  symptoms  of  ab- 

sorption in  two  weeks — Prompt  removal  of  paste  resulted 

in  complete  recovery  and  cure 197 


16  ILLUSTRATIONS. 

FIGURE  PAGE 

77.  Method  of  withdrawing  mixture  of  paste  and  olive  oil  twenty- 

four  hours  after  injection  of  the  latter 198 

78.  Syringe  and  attachments  for  injection  of  bismuth  paste  in  ear, 

nose,  and  throat  cases 206 

79.  Frontal    sinus    injected    with    bismuth   paste    No.    2    by    nasal 

route — Portion  of  the  bismuth  paste  in  the  ethmoid  region 
and  antrum 211 

80.  Radical  operation  on  antrum  and  filled  with  paste  No.  2    .     .     .  213 

81.  Cyst  of  lower  maxilla  filled  with  bismuth  paste 224 


BISMUTH  PASTE   IN.- CHRONIC 
SUPPURATIONS. 


CHAPTER  I. 
INTRODUCTION. 

BY   CAEL   BECK,    M.    D. 

Ever  since  we  have  used  aseptic  methods  in  surgery, 
chronic  suppurations  have  decreased  in  number.  The 
difference  between  the  old  surgical  ward  of  twenty-five 
years  ago,  reeking  with  the  sweetish,  repulsive  odors  of 
pus,  mingled  with  the  smell  of  carbolic  acid,  and  the  pure 
air  of  the  modern  hospital  is  a  striking  one.  Most  of 
our  cases  of  operative  surgery  heal  by  primary  union. 
Nevertheless,  there  are  many  victims  of  chronic  suppura- 
tive conditions,  and  they  are  all  the  more  disappointing 
because  the  surgeon  demands  more  from  his  art  now- 
adays; he  expects  healing  by  first  intention  where  he  was 
formerly  well  satisfied  with  the  appearance  of  pus  (jnts 
bonum  et  laudabile) .  Rebellious  and  refractory  cases 
become  a  source  of  disappointment  to  both  surgeon  and 
patient,  particularly  when  they  fail  to  heal  after  several 
operative  attempts.  It  is  then  that  the  afflicted  wander 
for  years  from  surgeon  to  surgeon,  to  persons  engaged  in 
irregular  methods,  and  then  back  to  regular  surgery,  dis- 
tressed and  unhappy,  or  they  often  become  resigned  to 
the  fate  of  a  cripple  who  despairs  of  ever  being  helped. 
For  a  number  of  years  I  have  been  watching  such  cases, 
of  which  I  saw  many  in  hospital  and  private  practice. 

17 


18         BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

Many  of  them  were  affected  with  diseases  of  the  bones, 
and  had  undergone  a  number  of  operations  in  the  course 
of  years.  When  the  discovery  of  the  x-ray  was  announced, 
it  was  taken  up  with  enthusiasm.  It  was  thought  that  it 
would  help  in  diagnosis  of  bone  lesions,  and  it  seemed 
to  me  that  a  new  ray  of  hope  had  come  into  the  lives  of 
these  unfortunate  patients.  The  early  pictures  of  bone 
lesions  were,  however,  rather  imperfect,  and  helped  little 
in  diagnosis. 

One  of  the  most  difficult  problems  in  this  connection 
seemed  to  me  the  question  of  how  to  make  bone  lesions 
distinct  in  the  picture,  and  particularly  how  to  follow 
those  suppurative  conditions  to  the  focus  of  their  origin. 
When  I  learned  of  the  favorable  results  obtained  by  the 
use  of  bismuth  in  the  stomach  diagnosis,  I  immediately 
thought  of  the  possibility  of  using  it  to  outline  the  fis- 
tulous tracts  and  to  follow  them  up  to  their  origin.  It 
took  some  experimenting  before  we  found  the  right  kind 
of  vehicle  which  would  allow  liquefaction  and  then  be- 
come solid  in  the  tract,  and  which  would  enter  into  the 
smallest  crevices  and  at  the  same  time  permit  the  sub- 
stance to  come  out  again.  We  first  tried  gelatin,  then 
water,  gum  arabic,  and  other  material,  but  they  all 
proved  failures  until  heated  vaselin  solved  the  problem. 
Our  first  case  gives  a  beautiful  picture.  (Fig.  2.)  When 
the  injected  mass  failed  to  return,  causing  us  to  fear  that 
we  had  stopped  up  the  sinus  and  possibly  infected  the 
medullary  canal,  we  felt  great  anxiety.  When  we  ob- 
served, however,  that,  instead  of  fever  and  sepsis,  a  dry- 
ing up  and  closure  of  the  sinus  followed,  we  were  at  first 
surprised,  and  then  we  began  to  experiment  systematic- 
ally on  other  cases.  We  studied  the  method  from  all  points 
of  view,  and  in  all  possible  localities  and  varieties  of 
cases.    Dr.  Emil  Beck  devoted  a  great  deal  of  his  time  to 


INTRODUCTION.  19 

this  study,  and  spared  no  efforts,  first,  to  arrive  at  recog- 
nizable facts,  and,  second,  to  apply  these  facts  and  to 
show  their  application  to  others.  He  published  a  number 
of  articles,  demonstrated  cases  of  different  character,  and 
tried  the  methods  in  different  institutions  and  with  other, 
often  skeptical,  surgeons.  We  may  say  with  satisfaction 
that  the  method  has  aroused  a  great  deal  of  general  in- 
terest, and  has  elicited  favorable  comment  from  surgeons 
who  are  using  it. 

When  the  inquiries  about  the  method  became  so 
numerous  that  we  could  not  supply  reprints,  and  we  had 
gathered  enough  experience  with  the  method  to  enable  us 
to  speak  with  some  authority,  we  decided  to  condense  this 
experience  into  a  small  book,  which  would  contain  the 
most  important  facts,  points  of  technic,  and  results. 

We  are  satisfied  that  the  same  results  may  be  obtained 
by  those  following  the  procedure  as  given  herein.  Modi- 
fications of  the  method  may  yield  good  results,  but  we 
have  found  the  technic  and  procedures  described  in  this 
volume  to  give  the  most  favorable  results.  One  fact, 
however,  is  of  importance,  even  in  the  simplest  method 
of  therapy — namely,  that  seeing  a  treatment  applied  is 
the  best  way  to  acquire  a  thorough  knowledge  of  the  pro- 
cedure. No  man  should  attempt  to  do  surgery  after 
having  studied  operative  procedures  merely  from  text 
books.  He  will  be  able  to  obtain  good  results  only  after 
witnessing  or  assisting  in  operations  for  some  time.  I 
remember  very  well  one  occasion,  while  I  was  still  an 
assistant  abroad,  when  a  celebrated  English  gynecologist 
visited  our  clinic.  In  the  visitor's  honor  our  chief  chose 
to  perform  one  of  the  Englishman's  methods  of  peri- 
neorrhaphy. When  the  operation  was  finished  our  visi- 
tor inquired  whose  method  it  was,  and  laughed  heartily 
when  he  was  informed  that  it  was  his  own.     This  method 


20         BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

was,  however,  very  simple,  and  had  been  well  described 
in  a  journal,  with  illustrations,  and  our  chief  was  a 
thorough  reader  of  medical  literature. 

In  our  diagnostic  work  we  make  extensive  use  of  bis- 
muth paste.  This  book  cites  many  instances  in  which 
errors  in  diagnosis  have  been  revealed  by  it,  and  our 
records  include  many  more  which  space  does  not  permit 
to  print.  This  phase  of  the  method  is  almost  univer- 
sally recognized  as  the  best  aid  to  the  surgeon,  and  I 
would  regard  any  operation  on  a  fistula  or  bone  lesion 
with  fistula  without  the  previous  use  of  bismuth  injection 
as  a  mistake. 

In  giving  this  book  to  the  profession  we  give  the 
methods  as  we  use  them  at  present,  but  we  are  not  using 
these  methods  to  the  exclusion  of  all  the  other  scientific 
therapeutic  methods  which  are  universally  recognized  in 
the  treatment  of  chronic  suppuration. 

There  is  no  question  that  chronic  suppurations  must 
be  analyzed  as  to  their  pathogenesis  and  must  be  treated 
with  different  methods.  The  injection  of  bismuth  paste 
Is  a  valuable  aid  in  diagnosis  and  treatment,  but  only  one 
of  many,  and  in  all  probability  its  principle  and  technic 
will  remain  a  therapeutic  method,  but  it  has  its  indica- 
tions and  also  its  limitations. 


CHAPTER  II. 
GENERAL  CONSIDERATION. 

Suppurative  sinuses,  especially  those  of  tuberculous 
origin,  have  always  been  most  refractory  to  both  medical 
and  surgical  treatment,  proof  of  which  may  be  found  in 
the  existing  mass  of  invalids  remaining  uncured  after 
the  most  skillful  treatment  has  been  employed.  The  ex- 
treme chronicity  accounts  for  the  accumulation  of  crip- 
ples all  over  the  world.  Several  individuals  in  my  series 
of  cases  have  been  afflicted  with  constant  and  extensive 
suppuration  for  from  thirty  to  forty  years,  and  managed 
to  drag  through  life  in  their  miserable  condition. 

A  keynote  to  the  prevalence  of  this  scourge  is  given 
in  his  studies  of  cripples  in  Germany  by  Biesalsky,1  in 
which  he  states  that  in  Germany  alone,  excluding 
Bavaria,  Baden,  and  Hessen,  there  exist  75,183  cripples. 
With  the  three  above-named  states  included,  their  num- 
ber is  89,048.  Of  every  10,000  children,  36  are  cripples, 
of  which  number  6  are  afflicted  with  tuberculous  joints  or 
bones.  Other  countries  are  no  doubt  equally,  if  not 
more  greatly,  burdened.  I  am  informed  by  physicians 
practicing  in  China  that  the  condition  of  suppurative 
sinuses  is  very  much  neglected  in  that  country,  and 
therefore  very  prevalent.  They  estimate  that  one  in 
every  four  hundred  Chinamen  is  afflicted  with  suppura- 
tive sinuses. 

These  sinuses  and  fistulas,  as  we  know,  are  sequelae  of 
infectious  processes  within  the  bones,  joints,  or  paren- 
chymatous organs.      Fortunately,  we  are  able  to   cure 


1  Biesalsky:  Zeitschrift  fur  Orthopedische  Chirurgie,  bd.  22,  s.  323. 

21 


22  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

most  cases  of  tuberculous  infection  in  their  early  stages, 
either  by  immobilization  or  through  hygienic  or  medical 
treatment,  so  that  only  a  small  percentage  will  terminate 
in  sinus  formation.  When,  however,  this  complication 
already  exists,  and  the  tendency  to  spontaneous  closure 
is  absent,  only  surgical  treatment  can  be  of  any  benefit. 
Even  surgical  treatment  is  here  uncertain,  and,  if  the 
sinus  can  not  be  traced  to  its  origin,  a  cure  by  operation 
is  almost  impossible. 

In  all  infections,  whether  acute  or  chronic,  there  exists 
a  natural  tendency  to  repair.  Our  system  responds 
quickly  to  all  infections — repelling  the  invading  organ- 
ism if  possible,  and,  whenever  it  fails  to  repel  it,  calling 
into  action  all  available  resisting  and  fighting  forces  to 
check  its  progress. 

The  wonderful  adaptation  of  the  various  types  of  cells 
to  the  needs  of  protection  of  the  life  of  the  individual  has 
been  aptly  compared  to  a  well-organized  state,  with  its 
soldiers,  its  working  and  professional  classes,  etc.,  who  in 
cooperation  and  perfect  harmony  render  their  services 
and  are  willing  to  perish  in  the  fight  for  preservation  of 
the  whole  organization.     (Adami.) 

The  production  within  the  body  of  various  protective 
substances — such  as  bacteriolysins,  opsonins,  antitoxins, 
etc. — and  also  the  well-known  action  of  the  white  blood 
corpuscles  called  phagocytosis,  are  all  contributing  fac- 
tors to  the  preservation  of  the  life  of  the  individual. 

Our  body  can  take  care  of  a  certain  amount  of  injury 
or  infection  without  in  the  least  disturbing  the  health  of 
the  individual.  In  fact,  mild  and  frequent  infections 
create  an  immunity  against  the  very  poison  produced  by 
the  microorganism  which  caused  the  infection.  Only 
when  our  resisting  forces  are  below  par,  and  the  invad- 
ing microorganisms  find  us  unprepared,  will  they  be  able 


GENEKAL  CONSIDERATION.  23 

to  get  a  foothold  and  develop  into  a  powerful  and  de- 
structive enemy. 

Our  resisting  power  is  influenced  by  general  and  local 
conditions.  Each  individual  inherits  a  certain  degree  of 
resisting  power  against  diseases,  which  is  either  strength- 
ened or  weakened  by  various  conditions.  One  may,  for 
instance,  inherit  the  tendency  to  tuberculosis,  but  may 
not  contract  it  as  long  as  he  lives  in  favorable  surround- 
ings. Should  he,  however,  suddenly  change  his  environ- 
ment and  live  among  consumptives,  he  is  more  liable  to 
contract  it  than  one  similarly  predisposed,  but  who  from 
childhood  has  lived  in  the  midst  of  consumptives.  The 
latter  has  by  constant  exposure,  and  probably  by  repeated 
and  very  mild  tubercular  infections,  acquired  an  immu- 
nity against  the  tubercle  bacillus. 

Every  person  can  increase  his  resisting  power  by 
proper  hygienic  life,  by  wholesome  nutrition,  and  the 
physiologic  exercise  of  all  normal  functions  of  the  body. 
By  disregarding  these,  especially  through  dissipation, 
alcoholism,  etc., he  is  bound  to  produce  the  opposite — "a 
lowering  of  vitality."  Conditions  beyond  his  control — 
such  as  climate,  constitutional  diseases  (diabetes,  rheu- 
matism, and  various  forms  of  anemia,  etc.),  and  malnutri- 
tion— are  other  factors  affecting  his  resisting  power. 

Mental  influence  upon  resisting  power  is  a  factor  prob- 
ably much  underestimated.  Many  patients  have  been 
scared  into  their  graves,  and  many  have  escaped  a  pre- 
mature death  through  their  optimism.  Worry  and  anger 
impair  man's  resisting  power. 

Local  immunity  as  well  as  predisposition  to  infection 
are  dependent  upon  several  factors.  Oft-repeated  expo- 
sure or  prolonged  mild  local  infection  will  produce  local 
immunity.  The  different  types  of  cellular  structures  have 
different  degrees  of  resistance,  the  highly  organized  cells 


24  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

being  less  resistant  than  the  coarser  connective  tissue 
cells.  Denudation  of  the  skin  or  mucous  membrane  and 
the  lack  of  blood  supply  will  also  favor  infection.  Patho- 
genesis is,  therefore,  entirely  dependent  upon  the  strength 
of  our  resisting  forces  and  the  virulence  and  tenacity  of 
the  invading  foe,  "the  pathogenic  microbe." 

In  the  struggle  between  the  invading  germs  and  the  re- 
sisting forces,  inflammation  is  always  present.  In  most 
instances  the  inflammatory  process  terminates  in  suppu- 
ration. In  very  acute  infections  a  diffuse  cellulitis,  also 
termed  "phlegmonous  infiltration,"  without  pus  forma- 
tion, will  be  produced,  while  in  the  subacute  or  chronic 
conditions  an  abscess  will  form. 

Formation  of  Abscess  and  Sinuses. 

An  abscess  is  a  circumscribed  accumulation  of  pus  in 
one  or  more  communicating  pockets,  formed  by  the 
products  of  inflammation. 

The  term  empyema  refers  to  an  accumulation  of  pus 
within  a  cavity  already  existing,  such  as  the  pleura,  peri- 
cardium, or  antrum  of  Highmore,  etc. 

The  character  of  the  contents  of  abscesses  varies  ac- 
cording to  the  character  of  the  infection.  In  acute  cases, 
such  as  are  due  to  the  streptococcus,  the  pus  is  thin  and 
scanty,  while  in  the  more  chronic  forms,  such  as  follow 
the  staphylococcus  infection,  the  pus  is  thick  and  abun- 
dant. The  contents  of  a  tuberculous  abscess,  when  origi- 
nating from  caries  of  bone  or  joints,  is,  as  a  rule,  a 
watery  fluid,  containing  the  tuberculous  debris,  which 
consists  of  a  quantity  of  whitish  or  gray  curds  and 
cheesy  masses,  and  at  times  also  contains  small  particles 
of  bone.  When  the  tuberculous  abscess  originates  from 
a  diseased  lymph  gland,  a  kidney,  or  other  parenchyma- 
tous organ,  the  character  of  the  pus  is  creamy  and  re- 
sembles that  produced  by  staphylococcus  infections. 


GENERAL  C0NS1DEKATI0N.  25 

The  cytologic  differences  are  likewise  dependent  upon 
the  various  types  of  infection.  In  acute  forms  the  poly- 
morphonuclear leucocytes  predominate,  while  in  the 
chronic  forms  the  lymphocytes  are  more  abundant.  The 
fluid  from  tuberculous  abscesses  contains  a  small  num- 
ber of  leucocytes  and  occasionally  a  few  tubercle  bacilli, 
but  an  abundance  of  granular  material.  While  the  ba- 
cilli are  not  frequently  found  in  the  fluid  contents  of  the 
abscess,  they  are,  as  a  rule,  found  in  abundance  within 
the  abscess  wall,  which  is  called  the  pyogenic  membrane. 
In  the  early  stages  this  wall  is  somewhat  ragged  and  con- 
gested, but  with  chronicity  it  becomes  thickened  and 
smooth,  and  assumes  a  much  paler  appearance,  but  still 
harbors  the  living  tubercle  bacilli. 

These  tuberculous  abscesses  have  been  named  cold 
abscesses  because  they  do  not  produce  fever.  They  are 
apt  to  become  very  large  (especially  the  so-called  psoas 
abscess),  and  still  may  not  give  rise  to  any  dangerous 
symptom.  I  have  seen  a  child  having  an  abscess  nearly 
as  large  as  its  head,  without  rise  of  temperature  or  even 
much  discomfort.  These  cold  abscesses  have  a  tendency 
to  gravitation,  or,  rather,  to  undermine  the  tissues.  The 
pressure  within  the  abscess  will  force  the  pus  along  the 
fasciae  or  muscles  in  the  line  of  least  resistance  until  it 
reaches  a  place  so  near  the  surface  that  spontaneous  rup- 
ture may  easily  take  place.  The  opening  may  be  at  such 
distance  from  the  original  focus  of  the  disease  as  to  mis- 
lead in  the  diagnosis.  I  report  a  case  in  which  a  spon- 
dylitis of  the  tenth  dorsal  produced  a  sinus  opening  in  the 
neck,  which  up  to  the  time  of  the  bismuth  injection  was 
thought  to  be  the  result  of  tuberculous  adenitis. 

The  spontaneous  rupture  or  incision  of  these  cold  ab- 
scesses may  terminate  in  closure  and  final  cure,  but  their 
susceptibility  to  secondary  infection  after  incision  and 


26  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

drainage  has  made  this  procedure  almost  prohibitive. 
Surgeons  have  learned  from  experience  that  it  is  danger- 
ous to  incise  cold  abscesses,  as  the  majority  of  patients 
developed  high  fever  and  died  as  a  result  of  secondary  in- 
fection. Even  though  the  fever  subsides,  it  is  very  un- 
certain whether  the  suppuration  will  cease;  it  may  con- 
tinue, and  a  sinus  or  a  fistula  will  result. 

The  terms  sinus  and  fistula  are  often  used  synony- 
mously. We  shall  in  this  work  adopt  the  following  defi- 
nitions: 

Fistula  is  an  abnormal  channel  existing  between  hol- 
low organs,  such  as  the  stomach,  gall  bladder,  rectum, 
urinary  bladder,  etc.,  or  between  the  skin  and  these 
organs. 

Sinus  is  a  suppurating  channel  which  has  its  origin 
in  connective  tissue  structures,  such  as  bones,  joints, 
muscles,  etc.,  or  in  the  parenchymatous  organs,  such  as 
the  liver,  glands,  kidney,  etc. 

A  sinus  has  a  granulating  wall,  which  itself  is  not  the 
source  of  the  suppuration,  but  is  simply  the  conducting 
channel  for  the  flow  of  pus  from  the  focus  of  infection, 
and  is  thus  constantly  bathed  by  the  purulent  secretions. 
The  chronicity  of  the  suppuration  produces  a  thickening 
and  hardening  of  the  connective  tissue  wall.  It  is  thus 
evident  that  these  sinuses  are  nothing  more  than  the 
shrunken  remains  of  abscess  cavities,  and  not,  as  is  often 
supposed,  an  ulcerating  process  burrowing  into  the 
depth  of  the  tissues.  A  sinus  is  practically  always  pre- 
ceded by  an  abscess. 

The  pictures  of  the  network  of  sinuses,  as  demon- 
strated by  the  radiographs  with  bismuth  paste  injec- 
tions, teach  us  that  the  abscess  is  not  always  one  globular 
sac  of  pus,  but  that  the  infected  region  is  permeated  by 
an  irregular  arrangement  of  a  number  of  pus  pockets, 


GENERAL  CONSIDERATION.  27 

communicating  by  cither  narrow  or  wide  channels. 
They  may  open  in  several  places,  at  some  distance  from 
one  another,  and  still  originate  in  the  same  focus.  In 
one  of  my  cases  of  knee  joint  tuberculosis  forty-two 
sinuses  existed  before  treatment  was  commenced — all 
communicating. 

I  trust  that  the  preliminary  remarks  with  reference  to 
the  origin,  development,  and  anatomy  of  sinuses  and  ab- 
scesses will  aid  the  reader  in  understanding  the  rational 
application  of  bismuth  paste  in  the  various  forms  of 
chronic  suppurative  diseases  discussed  in  the  succeeding 
chapters. 


CHAPTER  III. 
BISMUTH   PASTE   IN   ANATOMICAL   DIAGNOSIS. 

In  the  foregoing  chapter  we  pointed  out  the  fact  that 
the  sinuses  frequently  open  at  a  distance  from  the  seat 
of  the  disease,  and  that  their  course  may  be  very  tor- 
tuous and  cause  a  labyrinth  of  suppurating  channels. 
The  truth  of  this  assertion  is  at  once  evident  when  one 
of  the  radiographs  of  the  sinuses  which  have  been  in- 
jected with  bismuth  paste  is  viewed. 

Technic  of  Injections. 

The  bismuth  paste  consists  of  the  following  mixture: 

Formula  No.  1. 

Bismuth  subnitrate   (arsen.  free) 33  percent. 

Vaselin  (yellow  or  white) 67  percent. 

It  is  prepared  by  first  boiling  the  vaselin  in  an  enameled 
jar  and  stirring  in  the  bismuth  powder  before  it  becomes 
cool.  Care  should  be  taken  not  to  spill  any  water  into 
the  mixture,  as  this  will  destroy  its  homogeneous  con- 
sistency and  thus  prevent  it  from  becoming  firm.  This 
forms  a  smooth,  yellow  paste,  which,  when  heated  over 
a  water  bath,  becomes  sufficiently  liquefied  to  facilitate 
its  being  drawn  into  a  glass  syringe  and  then  injected 
into  a  sinus. 

Fig.  1  illustrates  the  various  types  of  syringes  used 
for  the  bismuth  paste  injections.  The  glass  syringe  A 
is  the  one  most  generally  used,  and  may  be  had  in  various 
sizes  from  %  to  4  ounces.     The  glass  syringe  B  has  a 

28 


ANATOMICAL  DIAGNOSIS.  29 

curved  tip,  which  is  preferable  when  injecting  empyema. 
The  metal  syringes  C,  which  have  long  nozzles  and 
pointed  tips,  are  used  principally  in  rectal  work,  but  I 
find  them  also  practical  for  other  sinuses  where  the  open- 
ing is  very  small. 


Fig.  1.  Types  of  syringes  used  for  bismuth  paste  injections.  A,  glass  syringe 
for  sinuses  ;   B,  glass  syringe  for  empyema  ;   C.  metal  syringe  for  rectal  cases. 

Without  preliminary  irrigation  or  curettage  of  the 
sinus,  the  external  opening  is  cleansed  with  alcohol,  and 
then  the  conical  tip  of  the  syringe  is  placed  snugly  against 
the  opening,  so  as  to  fully  occlude  it.  Slowly  and  with 
gentle  force  the  liquefied  paste  is  injected  into  the  sinus 
until  the  patient  begins  to  complain  of  pressure,  or  when 


30 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


the  surgeon  feels  a  resistance  and  notes  the  overflow  of 
the  paste  around  the  tip  of  the  syringe. 

The  quantity  injected  varies  with  the  character  of  the 
sinus.  In  narrow  channels  1  or  2  drams  will  be  all 
that  the  sinuses  will  hold,  while  in  old  empyema  cavi- 


Fig.  2      Sinus  after  psoas  abscess.     A,  sinus  opening  ;   B,   small  abscess  cavity 
on  the  opposite  side. 

ties  the  quantity  may  reach  as  much  as  20  ounces.  It 
is,  however,  not  advisable  to  inject  more  than  100  grams, 
except  in  empyema,  where  a  large  drainage  opening- 
exists.  The  liquefied  paste  will  thus  penetrate  all  rami- 
fications of  the  sinuses,  and  on  cooling  will  remain  long 


ANATOMICAL  DIAGNOSIS.  31 

enough  within  them  to  permit  the  taking  of  a  radiograph 
of  the  injected  region.  The  radiograph  thus  produced 
will  furnish  a  true  picture  of  the  condition  existing  with- 
in the  diseased  region.  It  will  outline  with  perfect  clear- 
ness the  boundaries  and  ramifications  of  the  sinuses,  and 
in  many  instances  will  trace  the  path  to  the  original 
focus  of  the  disease. 

Stereoscopic  radiographs,  which  are  obtained  by  tak- 
ing two  pictures  of  the  same  region  from  two  different 
angles,  and  then  fusing  this  pair  of  radiographs  into  one 
by  means  of  a  pair  of  prisms,  are  of  the  utmost  value  in 
establishing  a  correct  anatomical  diagnosis.  They  bring 
before  one's  eyes  a  picture  in  which  all  structures  stand 
out  in  plastic  effect,  so  that  their  relation  to  one  another 
is  easily  estimated.  We  are  then  able  to  tell  whether  the 
injected  paste  runs  in  front  of,  behind,  or  through  a  bone. 

It  is  well  known  that  bismuth  will  produce  a  shadow 
on  a  sensitized  plate  when  placed  in  the  path  of  the  x-ray. 
This  principle  was  taken  advantage  of  in  tracing  sinuses 
for  anatomical  diagnosis  when,  in  March,  1906,  my 
brother,  Dr.  Carl  Beck,  of  Chicago,  injected  a  sinus  fol- 
lowing spondylitis,  illustrated  in  Fig.  2. 

A.  D.,  a  girl,  aged  4,  was  brought  to  the  North  Chicago  Hospital  in 
March,  1906,  with  a  discharging  sinus  in  Scarpa's  triangle.  History: 
spondylitis  with  psoas  abscess  at  the  age  of  2  years,  which  ruptured 
spontaneously  and  persisted  in  discharging  pus  for  two  years,  thus  re- 
quiring daily  dressing.  The  sinus  was  injected  March,  1906,  with  bis- 
muth paste  and  a  radiograph  taken.  This  picture  (Fig.  2)  clearly  shows 
the  sinus  tract  leading  from  the  opening  in  Scarpa's  triangle  to  the 
tuberculous  focus,  in  the  second  and  third  lumbar  vertebra?.  At  this 
point  the  paste  fills  out  a  space  about  three-fourths  of  an  inch  long  and 
one  and  one-quarter  inches  wide.  A  small  cavity  leads  to  the  other 
side  of  the  spine,  indicating  that  there  existed  a  tendency  to  the  forma- 
tion of  a  double  psoas  abscess. 

This  case  is  instructive  not  only  from  the  diagnostic 
standpoint,  but  from  the  therapeutic  as  well.  A  few 
days  later  the  parents  informed  us  that  the  sinus  had  for 


32  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

the  first  time  in  two  years  stopped  discharging.  This 
stoppage  was  then  considered  to  be  only  temporary,  but 
now,  after  fonr  years,  there  has  been  no  recurrence,  and 
the  child,  now  8  years  old,  is  in  perfect  health. 

The  advantages  of  this  advanced  anatomical  diagnosis 
are  manifold.  It  enables  us  to  study  the  topography  of 
the  sinuses  before  an  operation  is  decided  upon,  and  thus 
discrimnate  between  operable  and  inoperable  cases.  We 
now  see  this  class  of  diseased  conditions  in  an  entirely 
new  light.  Most  of  us  will  recall  instances  in  which  such 
pictures  would  have  been  of  inestimable  value,  when  they 
would  have  explained  the  causes  of  failure  in  operations. 
These  operations  at  the  time  seemed  to  be  most  radical, 
but  in  the  light  of  our  recent  knowledge  of  the  complex- 
ity of  these  sinus  tracts  they  must  have  been  incom- 
plete— some  of  the  sinuses  must  have  remained  unex- 
plored. 

The  older  methods  of  diagnosis,  such  as  the  probe  or 
the  employment  of  colored  fluids  to  stain  the  tracts,  must, 
in  the  light  of  this  new  diagnostic  method,  appear  unre- 
liable. The  probe  may  enter  one  of  the  sinuses  and  give 
us  no  idea  whatever  as  to  its  depth.  It  may  enter  a  blind 
pocket  or  a  fold  of  the  sinus,  and  leave  us  under  the  im- 
pression that  it  has  reached  its  end,  while,  in  fact,  there 
may  exist  a  network  of  sinuses  beyond  our  conception. 
Such  condition  is  well  illustrated  in  Fig.  3,  where  the 
probe  entered  at  A  and  reached  down  to  B,  and  led  us  to 
repeated  operations,  all  of  which  were  failures,  until  the 
injection  of  bismuth  paste  revealed  the  existence  of  this 
extensive  network  of  channels.  This  diagnostic  injection 
resulted  in  a  complete  cure. 

The  injection  of  methylen  blue  to  stain  the  walls  of 
the  sinuses,  in  order  to  facilitate  tracing  them  during 
the   operation,   is   likewise   objectionable.     In   the   first 


ANATOMICAL  DIAGNOSIS.  33 

place,  it  does  not  permit  the  study  of  the  extent  of  the 
tracts  before  the  operation.  The  sinuses  may  extend 
into  inaccessible  regions,  and  this  may  not  be  discovered 
until  the  patient  has  been  subjected  to  the  operation,  and 
often  after  he  has  been  an  hour  or  two  on  the  operating 
table.  Furthermore,  the  stained  sinuses  are  often  losl 
track  of  by  distortion  and  bloody  discoloration  of  the  tis- 
sues during  the  operation. 


Fig.   3.      Network  of  sinuses  following  tuberculosis  of  iliac  bone.     A,  sinus  open- 
ing ;  B,  supposed  bottom  of  sinus. 


The  employment  of  peroxide  of  hydrogen  for  diag- 
nosis has  no  other  value  than  to  aid  us  in  ascertaining 
whether  a  fistula  communicates  with  a  hollow  organ  or 
with  another  sinus. 

By  our  new  method,  if  properly  carried  out,  it  is  al- 
most impossible  to  miss  any  of  the  sinuses.  That  the 
paste  may  reach  even  the  most  minute  tracts  is  amply 
demonstrated  when  we  examine  Fig.  4,  which  represents 


34 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


Fig.  4.     Bronchial  tree  of  a  eat  injected  with  bismuth  paste  to  show  that  the 
smallest  channels  can  be  reached. 


the  bronchial  tree  of  a  cat,  injected  with  the  liquefied 
bismuth  paste.  We  note  that  even  the  smallest  bronchi- 
oles have  been  reached. 


CHAPTER  IV. 

DIAGNOSTIC  ERRORS  REVEALED  BY  BISMUTH 
PASTE  INJECTIONS. 

We  have  demonstrated  by  means  of  the  paste  injec- 
tions and  radiographs  that  abscesses  very  often  open  at 


Fig.  5.     Osteomyelitis  of  femur,  mistaken  for  hip  joint  disease. 

a  distance  from  their  origin,  and  thus  the  sinus  opening  is 
placed  in  a  region  which  appears  to  have  no  anatomical 

35 


36  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

relation  with  the  original  focus  of  disease.    "Without  the 
picture  of  the  sinus  tracts  before  us,  this  may  lead  to  false 
diagnosis,  and  consequently  to  wrong  treatment. 
This  is  not  at  all  theoretical.     I  will  cite  a  variety  of 


Fig.   6.     Tuberculous  sinus  originating  in  the  sacrum,  thought  to  be  an  abscess 
of  hip. 


examples  which  illustrate  most  lucidly  that  faulty  diag- 
nosis was  responsible  for  the  failure  in  treatment,  and 
that  in  most  of  the  cases  a  cure  was  obtained  as  soon  as 
the  correct  diagnosis  was  made. 


DIAGNOSTIC!  KKIiOKS  KKVKALKD. 


?>1 


Example  1.  Osteomyelitis  of  Femur  Treated  for  Hip  Joint  Disease. 
— Mr.  C,  aged  26,  farmer,  gives  the  following  history:  at  the  age  of 
23  he  developed  a  large  abscess  about  his  hip.  An  incision  and  drain- 
age left  a  discharging  sinus.  A  year  later  an  operation  for  hip  joint 
disease  was  performed,  which  failed  to  produce  a  cure.  Later  the  area 
of  suppuration  was  increased,  so  that  four  sinuses  resulted.  These 
sinuses  were  repeatedly  curetted,  but  without  avail.     The  radiograph 


Fig.   7.      Bismuth   paste  remaining  in  focus   of  disease   four   months   after  clo- 
sure.    Hip  shown  to  be  normal.      (Case  shown  in  Fig.  6.) 

(Fig.  5),  taken  after  injection  of  the  paste  for  diagnostic  purpose,  re- 
vealed the  fact  that  the  hip  joint  was  not  affected  at  all,  but  that  it 
was  the  shaft  of  the  femur  which  was  the  original  source  of  infection, 
and  that  at  this  source  there  was  also  a  sequestrum,  the  removal  of 
which  produced  a  closure  of  three  sinuses  within  a  month.  The  fourth 
sinus  kept  on  discharging  some  serous  fluid,  but  otherwise  caused  no 
inconvenience.  Patient  gained  forty-five  pounds  after  the  suppuration 
had  ceased. 


38 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


It  is  not  surprising  that  this  mistake  in  diagnosis  was 
made  by  a  number  of  competent  physicians,  because 
there  existed  severe  lameness,  and  even  some  shortening 
of  the  affected  limb,  but  our  radiograph  shows  distinctly 
that  the  head  of  the  femur  and  the  acetabulum  are  in- 
tact, and  no  connection  existed  between  the  large  abscess 
cavity  and  the  hip  joint. 


Fig.   8.      Tuberculosis  of  sacrum,  mistaken  for  hip  joint  disease. 


Example  2.     Abscess  at  the  Hip,  Originating  in  the  Sacrum. — R.  K., 

aged  13,  with  a  tubercular  family  history,  was  well  until  the  age  of  5, 
when  a  swelling  in  his  left  hip,  posterior  to  the  greater  trochanter, 
appeared.  An  abscess  ruptured  spontaneously  and  a  copious  purulent 
discharge  persisted  for  seven  years,  which  greatly  debilitated  the  boy. 
In  July.  1908,  he  was  given  the  first  injection  of  bismuth  paste  by  Dr. 
Dahl,  with  whom  I  saw  the  case.  The  radiograph  (Fig.  6)  disclosed 
the  fact  that  the  abscess  did  not  originate  in  the  hip  joint,  as  one 
would  suspect  from  the  location  of  the  sinus,  but  that  it  communicated 


DIAGNOSTIC  EKKORS  REVEALED. 


39 


with  the  original  focus  in  the  sacrum  by  a  narrow  channel.  This  case 
proved  to  be  not  only  an  interesting  example  of  the  diagnostic  value 
of  bismuth  paste,  but  it  likewise  credited  the  therapeutic  account  with 
a  cure  of  which  both  the  doctor  and  patient  are  justly  proud.  A  radio- 
graph (Fig.  7)  taken  a  few  months  after  closure  shows  a  small  Quan- 
tity of  the  paste  still  in  the  original  focus. 

Example  3.  Tuberculosis  of  Sacrum  Mistaken  for  Hip  Joint  Disease. 
— J.  F.,  aged  36,  presented  himself  for  treatment  of  a  sinus  about  the 
trochanter  of  his  right  hip.  This  sinus  had  existed  for  several  years, 
and  had  been  treated  with  washes  and  cauterization,  but  no  surgical 


Fig.   8  A.      Diagrammatic  illustration  of  Fig.  8. 


treatment.  It  was  thought  to  originate  from  his  hip  joint.  The  radio- 
graph (Fig.  8)  clearly  demonstrates  that  the  hip  is  entirely  free  from 
disease,  and  that  the  sinus  originates  in  the  sacrum.  The  shadow 
of  the  injected  paste  traces  the  tract  to  the  focus  of  infection — namely. 
the  sacrum;  there  it  fills  out  the  ring  around  the  diseased  section  and 
traces  another  tract  running  to  the  hip  on  the  opposite  side,  which 
terminates  in  a  blind  end. 

This  case  teaches  its  that  a  sinus  opening-  near  the  hip 
does  not  necessarily  mean  hip  joint  disease,  but  that  it 


40  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

may  exist  as  a  result  of  a  disease  in  the  sacrum  or  the 

spine. 

Example  4.     Subphrenic  Abscess   Following  Appendicitis. — A.  L.,  a 

robust  cab  driver,  aged  27,  was  suddenly  attacked  in  July,  1909,  with 
an  acute  appendicitis.  An  emergency  operation  consisted  in  removing 
a  ruptured  gangrenous  appendix;  diffuse  peritonitis  was  present.   With 


Pig.  9.      Subphrenic  abscess  following  appendicitis,  suspected  of  being  an  empyema. 

good  drainage,  in  Fowler's  position,  and  with  continuous  (Murphy) 
irrigation,  I  succeeded  in  carrying  him  over  the  shock,  and  four  weeks 
later  he  left  the  hospital  with  the  abdominal  wound  closed.  His  tem- 
perature, however,  still  rose  to  100°  or  101°  every  day,  and  he  com- 
plained of  pain  in  his  chest.  This  condition  became  much  aggravated, 
and  within  a  week  he  developed  a  cough  and  suddenly  expectorated 
large  quantities  of  green,  very  fetid  pus.  At  this  time  the  abdominal 
wound  also  reopened  and  discharged  the  same  character  of  pus.     An 


DIAGNOSTIC  KKKOKS  RKVKALKD. 


41 


injection  of  the  paste  at  the  appendix  incision  proved  that  the  original 
abscess  of  the  appendix  communicated  with  a  subphrenic  abscess,  and 
that  the  latter  had  evidently  ruptured  into  a  bronchus,  as  he  expec- 
torated a  portion  of  the  injected  paste.  A  radiograph  (Fig.  9),  taken 
a  few  days  later,  verified  our  diagnosis.  The  patient  was  treated  with 
injections  of  the  bismuth  paste,  of  which  he  regularly  coughed  up  a 
part.  The  lung  is  now  entirely  clear,  cough  has  ceased,  and  the  sinus 
is  closed.     The  patient  has  gained  thirty  pounds. 

Aside  from  the  favorable  therapeutic  result  obtained,  the  diagnosis 


/  opening 

Fig.   9  A.      Diagrammatic  illustration  of  Fig.  9. 


was  greatly  facilitated  by  the  injection.  The  diagnosis  rested  between 
subphrenic  abscess  and  empyema,  but  our  radiograph  removed  all 
doubt  as  to  the  correctness  of  the  diagnosis  of  subphrenic  abscess. 

Example  5.  Unsuspected  Renal  Sinus. — R.  P.,  boy,  aged  10,  has  a 
sinus  in  his  left  lumbar  region,  which  has  persisted  in  discharging  pus 
for  about  two  years  following  an  operation  of  an  abscess  within  the 
pelvis.  The  radiograph  (Fig.  10)  brings  out  the  surprising  fact  that 
the  sinus  extends  not  only  downward  into  the  pelvis,  but  that  another 
channel  exists  and  extends  upward  into  the  kidney,  and  there  the  paste 
maps  out  the  contour  of  the  pelvis  of  the  kidney.     This  cleared  up  the 


42 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


diagnostic  puzzle  as  to  why  the  sinus  secreted  large  quantities  of  wa- 
tery secretions  (as  much  as  10  ounces  a  day)  in  addition  to  occasional 
discharges  of  pus. 

We  could  cite  many  similar  examples,  but  these  are 
sufficient  to  show  the  diagnostic  possibilities  of  the  paste 
in  clearing  for  us  diagnostic  errors. 


Fig.  10.  Unsuspected  renal  sinus  diagnosed  by  bismuth  paste  injection.  A, 
renal  pelvis  ;  B,  pelvic  abscess  ;  C,  sinus  opening  for  both. 

In  no  other  condition  are  the  diagnostic  errors  more 
frequent  than  in  rectal  fistula.  This  will  be  elucidated 
in  the  chapter  on  treatment  of  that  affection. 


DIAGNOSTIC  ERKORS  REVEALED. 


43 


Fig.   10  A.      Diagrammatic  illustration  of  Fig.  10. 


CHAPTER  V. 
THERAPEUTIC    EFFECTS    OF    BISMUTH    PASTE. 

The  teclmic  employed  in  the  therapeutic  application 
of  the  paste  is  practically  the  same  as  that  in  the  diag- 
nostic method.  The  paste,  formula  1,  which  consists  of  1 
part  of  bismuth  subnitrate  and  2  parts  of  vaselin,  is  em- 
ployed in  the  first  injection.  Should  it  be  desired  to  em- 
ploy a  firmer  paste  for  longer  retention,  the  following 
formula  may  be  employed: 

Fokmula  No.  2. 

Bismuth  subnitrate  30  percent. 

Vaselin    60  percent. 

Paraffin   (120°   melting  point) 5  percent. 

White  wax    5  percent. 

The  minor  details  and  rules  for  the  frequency  of  injec- 
tions will  be  fully  treated  in  the  description  of  typical 
cases. 

Sufficient  time  has  now  elapsed,  and  an  abundance  of 
cases  have  been  treated  with  bismuth  paste  in  all  parts  of 
the  world,  to  permit  making  an  estimate  of  its  thera- 
peutic value.  Let  us  review  the  literature,  analyze  the 
statistics,  and  then,  by  proper  classification  of  cases,  de- 
termine how  this  method  compares  with  other  forms  of 
treatment. 

The  curative  effects  of  bismuth  paste  were  first 
observed  in  August,  1907,  about  one  year  after  inception 
of  its  use  for  diagnostic  purposes.  The  following  case 
was  the  first  in  which  the  therapeutic  effect  was  tested: 

M.  Y.,  aged  14;  born  in  Germany;  lived  there  until  1903;  family 
history   negative.     He    was    healthy   until    he    was    7   years   old,    when 

44 


Til  i:i;Ai'i;i  tic  ki<  ikctk. 


45 


he  developed  a  painful  swelling  in  his  right  knee.  A  cast  was  put 
on  by  his  family  physician  for  the  purpose  of  immobilization.  In  a 
short  time  an  abscess  ruptured;  the  boy  was  transferred  to  the  hos- 
pital at  Freiburg,  in  Germany,  and  an  operation  was  performed  for 
tuberculosis  of  the  knee  joint.  He  left  the  hospital  seven  weeks  later, 
with  a  sinus  extending  from  the  knee  joint  into  the  middle  of  the 
tibia,  and  two  smaller  ones  near  the  joint. 


Fig.  11. 
closure. 


Tuberculous  knee  joint,  showing  remnants  of  paste  four  months  after 


A  short  time  later  he  returned  to  the  hospital  for  another  opera- 
tion, which,  however,  failed  to  close  the  sinuses,  and  a  third  opera- 
tion was  performed  two  months  later,  again  with  an  unfavorable  re- 
sult. The  parents  then  took  the  boy  to  Tubingen,  where  Professor 
Bruns  performed  the  fourth  operation.  No  improvement,  however, 
resulted;  the  three  fistulas  persisted  as  before.  The  family  then  moved 
to  America,  in  June,  1903.  They  had  abandoned  all  treatment;  noth- 
ing more  than  daily  dressing  was  done  by  the  patient  himself. 

On  March  21,  1907,  at  the  age  of  13,  six  years  after  the  commence- 


46         BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

ment  of  the  fistulse,  he  came  to  me  for  treatment.  A  radiograph  with- 
out bismuth  injection  was  first  taken.  It  shows  the  joint  and  the 
epiphyses  of  femur  and  tibia  nearly  destroyed,  and  a  sequestrum  is 
clearly  visible  in  the  tibia.  I  proposed  the  resection  of  the  knee  joint, 
which  was  refused,  but  the  next  best  procedure,  the  removal  of  the 
sequestrum,  was  consented  to.  This  was  done  March  29,  1907,  but 
the  three  sinuses  persisted. 

The  first  bismuth  paste  injection  was  made  October  3,  1907,  and 
sinuses  at  once  showed  a  tendency  toward  healing.  After  three  injec- 
tions, at  intervals  of  one  week,  they  nearly  closed,  and  it  was  with  diffi- 
culty that  I  made  the  fourth  injection.  Since  that  time  all  sinuses  have 
remained  healed,  the  boy  has  become  stronger,  and  the  pain  entirely 
disappeared,  so  that  he  could  discard  his  crutches,  which  he  had  used 
for  seven  years.  He  can  now  skip  up  and  down  stairs  on  the  tuber- 
culous limb,  and  can  take  part  in  all  the  athletic  sports  of  his  play- 
mates. His  weight  and  strength  are  those  of  a  normal  boy  of  his 
age.  The  radiograph  (Fig.  11)  presents  the  condition  as  it  existed 
four  months  after  closure  of  the  sinuses,  it  showing  a  small  portion 
of  the  paste  still  within  the  cavity  which  held  the  sequestrum,  but 
the  paste  which  had  been  in  the  epiphysis  of  the  femur  is  nearly  ab- 
sorbed; only  a  few  specks  of  it  are  visible  in  the  picture. 

Encouraged  by  this  result,  I  tried  the  bismuth  injec- 
tion in  a  case  of  empyema,  and,  to  my  surprise,  the 
cavity,  which  had  suppurated  for  eight  months,  closed 
within  one  week  (case  reported  in  chapter  on  Empyema). 
Similar  cases,  such  as  sinuses  following  hip  joint  disease, 
tuberculous  kidney,  rectal  fistula?,  and  fecal  fistula?,  were 
put  to  the  test,  and  the  results  were  uniformly  favorable. 
Thereupon  I  traced  the  four  cases  which  in  the  previous 
year  were  injected  for  diagnostic  purposes,  and  found 
that  these  cases  also  had  in  the  meantime  healed.  Thus  I 
was  able  to  report,  in  January,  1908,  before  the  Chicago 
Medical  Society,1  14  cases,  10  of  which  were  then  cured, 
3  improved,  and  1  unimproved.  Ten  of  these  cases  were 
exhibited  at  the  meeting.  Now,  after  a  lapse  of  two 
years,  the  present  status  of  these  14  cases  is  as  follows: 


1 E.  G.  Beck:  A  New  Method  of  Diagnosis  and  Treatment  of  Fistulous 
Tracts,  Sinuses,  and  Abscess  Cavities. — Journal  American  Medical  Associa- 
tion, March  14,  1908. 


TIIKKAI'llliTKl   I  ;KH;<  ITS. 


47 


No.  of 
case. 

Number  of 

sinuses. 

Disease. 

Dui-jiI  Ion, 
years. 

Result. 

1 

1 

Spondylitis 

•; 

<  !losure,  1  years 

'> 

18 

Spondylitis 

If) 

Died,  l  year  alter  tre 

it  int.' 

8 

1 

Coxitis 

!l 

Closure,  '■'•',-i  years 

i 

9 

Coxitis 

[fi 

Closure,  2)4  years 

5 

8 

Tuberculous  knee 

7 

( 'insure,  ->y±  years 

6 

1 

Tuberculous  os 
ilium 

:\ 

Closure,  '■'>     years 

7 

1 

Tuberculous  ulna 

% 

Closure,  2     years 

8 

1 

Removal  tubercu- 
lous kidney 

1 

Closure,  \'A  years 

0 

1 

Rectal  fistula 

■j 

Closure,  214  years 

10 

1 

Rectal  fistula 

1 

Closure,  2'A  years 

11 

1 

Rectal  fistula 

A 

Closure,  2     years 

12 

1 

Abdominal  fistula 

of  the  appendix 

l 

Closure,  '_'     years 

13 

1 

Abdominal  fistula 
after  laparotomy 

y 

Closure,  2     years 

14 

1" 

Tuberculosis  of 
metacarpal  bone 

1 

Closure,  2     years 

Total,  11  cases;  cured,  13;  died,  1. 

Shortly  after  this  first  presentation  the  method  was 
taken  np  by  Drs.  Ridlon  and  Blanchard  at  the  Home  for 
Crippled  Children  in  Chicago.  It  was  tested  on  26  chil- 
dren, and  after  three  months'  treatment  the  following 
results  were  reported  by  them  at  the  June,  1908,  meet- 
ing of  the  American  Orthopedic  Association  i1 

9  cases  cured  in  which  sinuses  had  existed  from  one  to  eight 
years. 

4  cases  cured  in  which  an  abscess  was  opened  and  only  once 

injected. 
7  cases   were    improved    and    were    still    under   treatment    in 
which  the  sinuses  had  existed  from  two  to  three  years. 

5  cases  were  only  one  week  under  treatment;  result  undeter- 

mined. 
1  case  unchanged;  no  deaths. 
Total,  26  cases. 

These  cases  were  shown  to  the  members  of  the  associa- 
tion at  the  Home  for  Crippled  Children. 


1  Ridlon  and  Blanchard:  A  New  Method  of  Treating  Old  Sinuses. — Journal 
of  Orthopedic  Surgery,   September.  1908. 


48 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


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THERAPEUTIC  EFFECTS.  49 

These  26  were  not  selected  cases,  but  comprised  prac 
tically  the  entire  number  of  children  who  were  thBD 
afflicted  with  sinuses  at  the  institution;  some  of  them  had 
been  inmates  for  years  and  many  bedridden  for  mouths. 
A  treatment  which  produced  50  percent  of  cures  within 
a  period  of  three  months  must  certainly  have  been  a 
welcome  innovation  in  an  institution  of  this  character. 

Their  report,  corresponding  in  its  favorable  results 
with  that  of  my  own  series,  served  as  a  stimulus  to  other 
surgeons  for  its  further  application,  and  soon  after  my 
first  publication  reports  began  to  appear  in  medical  jour- 
nals here  and  abroad.  The  usual  conservatism  with  new 
methods  was  cast  aside  because  the  method  was  simple 
and  appeared  harmless,  and,  furthermore,  material  for 
testing  it  was  willing  and  plentiful  everywhere.  To  the 
unfortunate  invalids  who  had  nothing  to  lose  and  every- 
thing to  gain,  anything  new  in  the  way  of  treatment  was 
welcome.  Besides,  there  was  no  opposition  to  this  treat- 
ment, no  one  having  claimed  any  successful  remedy  for 
this  class  of  cases. 

Thus  in  October,  1908,  I  was  able  to  present  before  the 
International  Congress  on  Tuberculosis1 2  a  collective  re- 
port of  192  cases,  which  included  histories  of  cases 
treated  by  such  prominent  men  as  Drs.  Mayo,  Ochsner, 
McGuire,  Ridlon  and  Blanchard,  and  in  two  hospitals 
of  the  United  States  Navy.     Of  this  number, 

123  cases,  or  64  percent,  were  cured. 
55  cases,  or  28.5  percent,  were  improved  and  still  under  treat- 
ment. 
11  cases,  or  6  percent,  were  unimproved  and  still  under  treat- 
ment. 
3  cases,  or  1.5  percent,  died  during  the  period  of  treatment. 


1  E.  G.  Beck:  Surgical  Treatment  of  Tuberculous  Sinuses  and  Their  Pre- 
vention.— Transactions  Sixth  International  Congress  on  Tuberculosis. 

2  E.  G.  Beck:  Diagnose.  Chirurgische  Behandlung.  und  Verhiitung  von  Fis- 
telgSngen  und  Abscess  Hohlen. — Beitrage  zur  Klinischen  Chirurgie.  1909,  bd. 
62,  h.  2. 


50 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


The.  pathological  classification  of  this  series  of  cases 
is  as  follows: 

143  cases  were  of  tuberculous  origin. 
23  cases  were  of  nontuberculous  origin. 
26  cases  were  of  doubtful  origin. 


Summary  Report  of  192  Cases  Treated  with  Bismuth  Paste  Method. 


Disease. 

Total 
number 
treated. 

Healed. 

Im- 
proved. 

Un- 
changed 

Died. 

Tuberculous  spondylitis  with  sinuses  . 
Tuberculous  hip  joint  with  sinuses  — 
Tuberculous    sacrum  a.nd   iliac  syn- 

26 
43 

7 
5 
4 

4 

12 

4 

3 

2 

3 

19 
0 
6 
6 
1 

16 
18 

7 

13 

21 

7 
4 
3 

4 
6 
3 
1 

2 

2 

14 

4 

4 
1 

13 
13 
5 

9 
19 

1 

1 

6 
1 

2 

3 

2 

1 
1 

Tuberculous  knee  joint  with  sinuses.. 

Tuberculous  wrist  joint  and  Angers 

Osteomyelitis  of  femur  with  sinuses... 

Osteomyelitis  humerus  with  sinuses.. 

Osteomyelitis  ulna  with  sinuses 

Tuberculosis  of  fascia  and  muscle  with 

4 

3 

1 

1 

1 
2 

1 

Empyema  and  tuberculous  lung  ab- 

Tuberculosis  of  ribs  with  sinuses 

Sinuses  following  tuberculous  glands. 

Sinuses  following  abdominal  opera- 

1 
5 
2 

1 

1 

Tuberculosis  of  kidney  with  sinuses... 

Total 

192 

123(1) 

55  (2) 

11(3) 

3(4) 

1  Or  64  percent. 

2  Or  28%  percent. 

3  Or  6  percent. 

*  Or  1%  percent. 


In  a  review  of  the  literature  on  the  uses  of  bismuth 
paste,  Dr.  Baer,  of  Johns  Hopkins  University,  makes  a 
comparative  study  of  percentages  of  cures  obtained  by 
different  surgeons.     His  report  is  as  follows: 


THERAPEUTIC  EKKECTS. 


51 


Number  of 
Name.  cases. 

Ochsneri     20 

Ridlon  and  Blanchard2 17 

Beck,   E.  G."-  4 192 

Robitschek*    0 

Don    (Edinburgh)  6 

Rosenbach     (Berlin)" 4 

Dollinger    (Budapest)* 16 

Beck,   Jos.  C.o 319 

Penningtonio     17 

Baer     (Baltimore)  n 12 


Disease. 

Percentage 
of  cures. 

Tubercular  sinuses 

55 

Tubercular  sinuses 

53 

Collective  report 

64 

Tubercular  sinuses 

55 

Tubercular  sinuses 

17 

Tubercular  sinuses 

50 

Tubercular  sinuses 

12% 

Accessory  sinuses 

22 

Rectal  fistula? 

70 

Tubercular  sinuses 

331/., 

Since  this  review  additional  reports  have  appeared  in 
the  literature  which  show  even  larger  percentages  of 
cures : 

Number  of  Percentage 

Name.                                        cases.                      Disease.  of  cures. 

Stern     (Cleveland)  12 4  Tubercular  sinuses  100 

Steinmann    (Miinchen)i" 5  Tubercular  sinuses  20 

Bogardusi4     1  Tubercular  sinuses  100 

Vidakovich     (Russia)is.  .' 2  Empyema  100 

Nemanoff   (St.  Petersburg)  1  c.  . .     6  Empyema  100 

Ochsner,   A.   J.17 14  Empyema  85 

Beck,  E.  G.    (Chicago)is 11  Empyema  82 

Ely   (New  York)19 14  Tubercular  sinuses  43 

Hines     (Cincinnati)-0 9  Tubercular  sinuses  89 

Cuthbertson     (Chicago)-i 1  Intestinal  fistulse  100 

Sandor,   Sag    (Budapest)  22 2  Otologic  100 

Heitz,  Boyer,  and  Morens 

(Paris)  23    11  Renal  sinuses  73 

Zollinger    (Zurich) 24 24  Tubercular  sinuses  54 

Schober    (Philadelphia) 25 5  Tubercular  sinuses  80 


*A.  J.  Ochsner:  Michigan  State  Medical  Society.  August,  190S. 

2  Ridlon  and  Blanchard:  A  New  Method  of  Treating  Old  Sinuses. — Journal 
of  Orthopedic  Surgery,  September,  190S. 

1  E.  G.  Beck:  Surgical  Treatment  of  Tuberculous  Sinuses  and  Their  Pre- 
vention.— Transactions  Sixth  International  Congress  on  Tuberculosis. 

*  E.  G.  Beck:  Diagnose,  Chirurgische  Behandlung  und  Verhiitung  von 
Fistelgangen  und  Abscess  Hohlen. — Beitrage  zur  Klinischen  Chirurgie.  1909. 
bd.  62,  h.  2. 

BRobitschek:  Beck's  Bismuth  Paste  Treatment  of  Sinuses. — Northwestern 
Lancet,  February  15,  1909. 

"Don:  Edinburgh  Medical  Journal.  February.  1909. 

7  Fr.  Rosenbach:  Zur  Wismutbehandlung  nach  Beck. — Berliner  Klinische 
Wochenschrift,  February  15,  1909. 

8  Dollinger:  Gumos  Eredetu  Talyogok  es  Sipolyok  Bismuth  Pastaval.  E.  G. 
Beck.— Orvosi  Hetilap,  1908. 

B  Jos.  C.  Beck:  Bismuth  Paste  in  the  Treatment  of  Suppuration  of  the 
Ear,  Nose,  and  Throat. — Journal  American  Medical  Association.  January  9, 
1909. 

10  Pennington:  Bismuth  Paste  in  the  Treatment  of  Rectal  Fistula. — Lancet 
Clinic,  December  26,  1908. 


52  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

The  results  obtained  vary  from  12V2  percent  to  100  per- 
cent of  cures  in  the  hands  of  different  surgeons.  The 
majority,  however,  have  obtained  a  cure  in  from  40  to 
60  percent,  except  in  empyema,  where  the  average  per- 
centage in  31  cases  reported  by  Nemanoff,  Ochsner,  Vida- 
kovich,  and  Beck  was  92  percent. 

These  reports  of  results  obtained  with  bismuth  paste 
by  surgeons  from  different  parts  of  the  world  should  con 
vince  even  the  most  skeptical  that  a  remedy  which  cures 
such  a  large  percentage  of  a  class  of  cases  formerly  con- 
sidered virtually  hopeless  is  of  practical  value. 

It  is  to  be  expected  that,  with  the  increasing  experi- 
ence and  perfection  in  our  technic,  the  failures  will  be 
reduced  to  a  minimum,  and  thus  the  results  obtainable 
will  be  more  uniform.  In  the  chapter  on  Causes  of  Fail- 
ure I  shall  explain  why  some  cases  do  not  respond  to  this 
treatment. 

The  following  rules  apply  to  all  cases: 

A  clear  history  of  each  case  should  be  obtained,  and  a 


uBaer:  Some  Results  of  the  Injection  of  Beck's  Bismuth  Paste  in  the 
Treatment  of  Tuberculous  Sinuses. — Johns  Hopkins  Hospital  Bulletin,  Octo- 
ber, 1909. 

12  Stern:  Bismuth  Injection  for  the  Treatment  of  Old  Sinuses. — Cleveland 
Medical  Journal,  April,   1909,  No.   203. 

13  Steinmann:  Mlinchener  Medizinische  Wochenschrift,  December,  1908,  No. 
49,  s.  2537. 

14  Bogardus :  Tuberculosis  of  Os  Sacrum  Treated  with  Bismuth  Paste. — 
Journal  American  Medical  Association,  vol.   54,   p.  701,  February  26,  1910. 

15  Vidakovich:  Centralblatt  fur  Chirurgie,   1908,   No.  49,   s.  1487. 

18  N.  J.  Nemanoff:  The  Treatment  of  Fistulas  and  Drainage  Passages. — 
Russki  Vratch,  No.  7,  p.  1568. 

17  A.  J.  Ochsner:  Treatment  of  Fistulas  of  Old  Empyema.- — Annals  of  Sur- 
gery, July,   1909,  p.  151. 

18  E.  G.  Beck:  Surgical  Treatment  of  Tuberculosis,  Pleurisy,  Lung  Abscess, 
and  Empyema. — Journal  American  Medical  Association,  December  18,  1909. 

19  Leonard  Ely:  Results  of  the  Use  of  Bismuth  Paste  in  Tuberculous  Si- 
nuses at  the  Sea  Breeze  Hospital,  New  York. — American  Journal  of  Surgery, 
January,  1910. 

20Hines:  Lancet  Clinic,   September  26,   1908. 

21  Cuthbertson:  Intestinal  Fistula  Closed  by  the  Use  of  Bismuth  Paste. — 
Illinois  Medical  Journal,  1909,  p.  348. 

22  Sag  Sandor:  Ueber  den  Heilwert  der  Bismuth  Paste  in  Otochirurgischen 
Fallen. — Pester.  Medizinische  Chirurgische  Presse,  1909,  No.  12. 

23  Heitz,  Boyer,  and  Morens:  Des  Injectiones  de  Pate  Bismuthee  en  Chirur- 
gie Urinaire. — Annales  des  Maladies  des  Organs  Genito  Urinaires,  June  1, 
1910. 

2*  Zollinger:  Beitrage  zur  Frage  der  Wismuthpastenbehandlung  Tubercu- 
loser  Fisteln  nach  Beck. — Schweizer  Rundschau  fur  Medizin,  No.  20,  May  21, 
1910. 

25  Schober:  Treatment  of  Chronic  Tuberculous  Sinuses  by  Beck's  Bismuth 
Vaselin  Paste  Injections. — Annals  of  Surgery,   No.  51,  p.  716. 


THERAPEUTIC  EFFECTS.  53 

thorough  physical  examination— without  any  probing, 
however — of  the  sinuses  should  be  made  in  order  to  de- 
termine whether  the  case  is  suitable  for  this  treatment. 
All  chronic  suppurative  sinuses,  fistula;,  or  abscess  cavi- 
ties, whether  of  tubercular  or  other  infectious  origin, 
with  the  exception  of  fistulas  of  the  gall  bladder,  pan- 
creas, or  those  communicating  with  the  cranium,  are 
suitable  for  the  bismuth  paste  treatment. 

Very  acute  inflammatory  conditions  are  not  suitable 
for  the  injections,  and,  while  some  good  results  have 
been  reported,  I  have  noted  even  aggravation  after  the 
treatment. 

After  we  have  decided  that  a  case  is  suitable  for  treat- 
ment, a  culture  and  a  smear  of  the  pus  should  be  made, 
and  the  sinuses  are  then  injected  in  the  same  manner  as 
described  in  the  diagnostic  method.  When  more  than 
one  sinus  is  present  and  the  paste  escapes  from  the 
various  openings  during  the  injection,  it  is  best  to  press 
small  pledgets  of  cotton  against  these  openings  and  pre- 
vent the  escape,  and  thus  force  the  paste  into  all  re- 
cesses of  the  fistulous  tract. 

I  have  made  it  a  rule  to  take  a  radiograph  also  before 
the  injection,  in  order  to  determine  whether  a  seques- 
trum is  at  the  seat  of  the  trouble. 

The  dressings  should  be  changed  daily.  If  the  dis- 
charge changes  from  a  purulent  to  a  serous,  the  injection 
need  not  be  repeated,  as  this  is  an  indication  that  the 
sinus  has  become  sterile,  and  one  may  expect  a  closure 
without  any  further  treatment.  Should  the  discharge 
remain  purulent,  it  is  best  to  wait  one  week  before  giv- 
ing the  second  injection. 

The  systematic  examination  of  the  secretion  should  be 
the  guide  for  the  frequency  of  injections.  As  long  as  the 
pus  contains  microorganisms,  it  is  almost  certain  that 


54  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

the  focus  of  the  disease  has  not  been  reached,  and  the  in- 
jections should  be  continued  for  a  reasonable  length  of 
time.  If  the  case  shows  no  tendency  to  healing,  then  the 
cause  of  failure  must  be  determined.  This  will  be  treated 
in  Chapter  XIII. 

Whether  the  chemical  or  mechanical  action  of  the 
paste  is  instrumental  in  bringing  about  these  striking 
results  has  been  discussed  by  many,  and  various  theories 
have  been  advanced,  but,  aside  from  plausible  sugges- 
tions, no  exhaustive  report  of  investigation  of  this  sub- 
ject has  as  yet  appeared  in  the  literature. 

Eidlon  and  Blanchard  have  drawn  their  conclusion 
from  clinical  observations,  and  state  that  they  believe 
the  beneficial  effects  from  the  paste  are  due  to  purely 
mechanical  action. 

Don,  of  Edinburgh,  and  Ryerson,  of  Chicago,  made  a 
suggestion  similar  to  one  advanced  by  Dr.  Dunning,  of 
Baltimore,  which  seems  plausible.  He  says:  "Is  it  not 
possible  that,  from  the  selective  action  of  nitric  acid  on 
tuberculous  and  other  pathological  tissues,  the  subni- 
trate,  when  acted  upon  by  organic  acids,  gives  up  its 
nitric  acid,  which  attacks  the  tubercular  wall  of  the 
cavity  and  forms  a  barrier  to  absorption,  and  to  further 
growth  of  tubercle  bacilli?" 

Dr.  Dunning  tested  samples  of  bismuth  subnitrate? 
from  various  manufacturers  in  order  to  determine 
whether  there  is  any  difference  in  the  time  they  hydro- 
lyze  at  a  given  temperature. 

The  results  were  striking;  each  preparation  gave  off  a 
different  quantity  of  nitric  acid  at  the  body  temperature. 
Some  preparations  hydrolyzed  from  five  to  ten  times  as 
rapidly  as  others. 

Dr.  Baer,  in  studying  this  matter,  made  the  deduction 
from  these  experiments  that  the  results  obtained  will 


THERAPEUTIC  EFFECTS.  55 

vary  according  to  the  amount  of  nitric  acid  given  off 
from  a  certain  preparation  of  the  subnitrate,  and  thus 
could  explain  some  of  the  failures.  His  own  experience 
would  bear  out  his  assertion.  He  used  the  same  technic, 
but  bismuth  from  different  manufacturers  at  two  differ- 
ent hospitals,  and  the  results  were  as  follows: 

All  his  cured  cases  were  at  the  Union  Protestant  In- 
firmary, while  at  the  Johns  Hopkins  Hospital,  in  the 
service  of  Professor  William  Halsted,  they  could  not 
obtain  a  single  closure.  Since  then  I  have  received  per- 
sonal information  from  Professor  Halsted  that  they  have 
obtained  satisfactory  results  at  their  clinic. 

From  my  personal  observation  and  from  the  bacterio- 
logical studies  of  the  secretions  in  over  500  cases  we  have 
formed  an  opinion  as  to  which  factors  cause  the  rapid 
improvement  following  the  injections  of  bismuth  paste. 
I  am  ready,  however,  to  change  my  opinion  if  more  posi- 
tive facts  are  offered  in  the  solution  of  this  problem. 

We  have  noted  that  in  most  instances  the  secretions 
have  changed  after  the  first  injection.  The  purulent, 
thick  discharge  assumes,  as  a  rule,  a  seropurulent  or  a 
serous  character.  This  is  considered  a  favorable  sign, 
since  the  sinuses  usually  close  rapidly  after  this  change 
in  the  secretion  has  taken  place. 

In  each  case  we  have  made  a  smear  preparation,  a  cul- 
ture, and  in  some  instances  inoculated  guinea  pigs,  to  test 
the  bactericidal  action  of  the  bismuth  paste.  Twenty- 
four  hours  after  the  first  injection  the  secretions  were 
again  bacteriologically  tested,  and  thereafter  the  test 
was  made  every  third  or  fourth  day.  As  a  rule,  the 
microorganisms  disappeared  in  twenty-four  hours  after 
the  first  injection,  but  in  a  certain  percentage  of  cases 
their  number  was  only  diminished,  and  cultures  would 
grow    a    little    slower.     In    many   instances    where   the 


56  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

growth  was  abundant   prior  to  the  injection   we   could 
obtain  no  growth  subsequent  to  the  first  injection. 

Tubercle  bacilli  are  no  exception  to  this  rule.  This 
fact  was  discovered  in  a  case  of  tuberculous  empyema 
(reported  in  my  series  of  cases  at  the  International  Con- 
gress on  Tuberculosis),1  in  which  tubercle  bacilli  were 
found  abundantly  in  the  pus  from  the  pleural  cavity 
previous  to  the  injection  of  bismuth.  After  the  injection 
their  number  gradually  diminished,  and  in  five  weeks 
they  could  not  be  found  by  microscopical  examination. 
For  illustration  I  cite  this  interesting  case: 

B.  H.,  aged  23,  law  student,  with  negative  family  history  as  to  tuber- 
culosis, developed  a  pleurisy  with  effusion  in  his  right  chest  in  Jan- 
uary, 1906.  In  May,  1906,  the  chest  was  aspirated  three  times  in  five 
days;  each  time  a  large  quantity  of  clear  fluid  was  withdrawn.  His 
chest,  however,  continued  to  refill  and  was  periodically  aspirated.  At 
the  ninth  aspiration  1,200  cubic  centimeters  of  turbid  fluid  was  re- 
moved. September  20,  1906,  he  went  to  Denver,  where  his  chest  was 
again  aspirated  three  times  by  Dr.  Bonney,  who  reported  that  tubercle 
bacilli  were  found  in  the  fluid  withdrawn.  On  his  return  to  Chicago, 
in  November,  1906,  he  consulted  Dr.  J.  B.  Herrick,  his  diagnosis  like- 
wise being  tuberculous  pleurisy  with  effusion. 

On  December  5,  1906,  an  operation  was  performed  in  Toledo,  which 
consisted  in  the  resection  of  five  ribs,  the  removal  of  a  large  amount 
of  fibrinous  lymph,  and  establishment  of  drainage.  The  large  cavity 
was  irrigated  daily  with  0.5-percent  iodin  solution  during  his  seven 
weeks'  stay  at  the  hospital,  and  thereafter  continued  at  home.  With 
the  above  history  he  was  referred  to  me  by  Dr.  Herrick  for  the  bis- 
muth treatment. 

Physical  examination  revealed  a  hyperresonance  over  his  entire 
right  chest.  A  fistulous  opening,  discharging  a  dark-green  pus,  was 
in  the  center  of  an  eczematous  area,  about  two  inches  below  the 
nipple.  Smear  preparations  from  the  pus  revealed  the  presence  of 
tubercle  bacilli,  five  to  fifteen  in  each  immersion  field,  and  a  moderate 
number  of  staphylococci. 

A  radiograph  clearly  showed  the  size  of  the  cavity  when  empty, 
and  another  when  injected  to  its  full  capacity  with  620  grams  of  33- 
percent  bismuth  paste.  The  drainage  tube  was  at  once  left  out,  and 
the  patient  allowed  to  be  outdoors.  Every  day  or  two  thereafter  the 
accumulation  of  pus   was   withdrawn   by  means   of  a  glass  tube  and 


1 E.   G.   Beck:  Surgical   Treatment   of  Tuberculous   Sinuses   and   their  Pre- 
vention.— Transactions   Sixth  International  Congress   on   Tuberculosis. 


THERAPEUTIC  EFFECTS.  57 

examined  microscopically.  Each  time  we  noticed  a  diminution  in  the 
number  of  tubercle  bacilli,  and  after  eight  weeks  their  final  disap- 
pearance. The  staphylococci  had  likewise  disappeared.  We  also  no- 
ticed that  the  tubercle  bacilli  which  were  found  after  the  bismuth 
had  been  injected  had  lost  their  characteristic  shape.  They  became 
granular,  beaded,  and  took  the  fuchsin  stain  more  readily. 

Microscopical  slides  were  submitted  at  different  periods  to  Dr. 
Maximilian  Herzog  and  Dr.  A.  Gehrmann,  bacteriologists,  whose  re- 
ports coincided  with  our  findings. 

Eight  guinea  pigs  were  injected  with  the  pus  discharged  during  the 
period  of  treatment  of  this  case. 

Animal  No.  4  was  injected  April  24  with  10  drops  of  a  10-percent 
solution  of  the  pus  taken  from  the  chest  before  the  bismuth  treatment 
was  instituted.  Animal  developed  general  tuberculosis  and  died  six 
weeks  later,  showing  tuberculosis  of  all  parenchymatous  organs  and 
glands. 

Animal  No.  9  was  injected  May  1  exactly  like  No.  4;  died  June  24. 
Liver,  lungs,  and  spleen  tuberculous. 

Animal  No.  13  injected  May  15  same  as  No.  4;  killed  July  15. 

The  report  of  findings  by  Dr.  M.  Herzog  is  as  follows: 

"Post-mortem  examination  of  guinea  pig  No.  13,  received  alive 
July  10  and  killed  July  15,  1908,  showed  caseous  enlarged  axillary 
lymph  glands  on  both  sides  and  caseous  enlarged  inguinal  lymph 
glands  of  the  right  side;  very  small  young  tubercles  in  the  liver  and 
spleen.  Smears  from  these  organs  showed  numerous  typical  tubercle 
bacilli. 

"Animal  No.  1G,  baby  guinea  pig,  weighing  240  grams,  was  in- 
jected June  7  with  150  drops  of  10-percent  solution  of  pus  from  chest 
cavity.  The  animal  has  grown  steadily,  weighing  360  grams,  and  is 
very  lively,  but  developed  two  lymph  glands  under  the  right  axilla, 
which  drained  the  injected  point.  One  of  the  glands  was  excised  for 
examination,  and  report  of  same  is  as  follows: 

"Sections  of  the  gland  of  guinea  pig  No.  16,  stained  by  various 
methods,  show  young,  not  very  much  degenerated,  tubercles,  with  a 
moderate  number  of  tubercle  bacilli." 

To  test  the  toxicity  of  the  discharge,  two  guinea  pigs  were  in- 
jected. Each  received  an  injection  of  15  cubic  centimeters  of  the  dis- 
charge (not  diluted)  intraperitoneally,  and  both  appeared  well  for  three 
days,  but  were  found  dead  on  the  fourth  day.  Post-mortem  revealed 
acute  peritonitis  in  both  animals. 

Animal  No.  21  was  injected  with  ten  drops  of  a  10-percent  dilution 
July  18,  and  kept  for  observation,  and  remained  perfectly  well  for 
months.     Post-mortem  revealed  no  tuberculous  disease. 

The  patient  was  cured  with  bismuth  injections. 

Another  case  quite  similar  to  the  one  just  quoted  was 
subjected  to  the  same  experiment,  and  the  results  proved 
to  be  identical  to  those  obtained  in  the  former. 


58  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

Froin  these  experiments  we  conclude  that,  while  the 
tubercle  bacilli  can  not  be  detected  by  the  microscope 
soon  after  the  institution  of  the  bismuth  treatment,  the 
discharge  must  still  contain  some  to  produce  tuberculous 
disease  in  guinea  pigs,  but  the  development  of  the  dis- 
ease is  much  slower  and  symptoms  much  milder  in  the 
animals  last  injected,  which  proves  that  the  number  of 
tubercle  bacilli,  as  well  as  their  virulence,  diminishes  as 
the  treatment  of  the  patient  progresses. 

If  the  rapid  diminution  and  disintegration  of  tubercle 
bacilli  noted  in  these  two  cases  is  not  accidental,  this 
disclosure  is  certainly  of  far-reaching  importance. 

Whether  the  bismuth  destroys  the  bacilli  by  its  chem- 
ical action,  or  whether  its  presence  acts  as  a  chemotactic, 
we  have  not  yet  determined,  although  the  evidence  pre- 
dominates that  its  chemotactic  property  accounts  for  the 
destruction  of  the  microorganisms. 

Tubercle  bacilli  are  not  often  found  in  the  pus  from 
tuberculous  sinuses;  more  often,  however,  in  tuberculous 
empyema.  They  lodge  in  the  granulations  and  the  walls 
of  sinuses  or  abscess  cavities  in  abundance.  The  bis- 
muth paste  coming  in  contact  with  the  walls  of  these 
sinuses  containing  the  bacilli,  and  thus  inducing  chemo- 
taxis,  is  instrumental  in  the  destruction  of  the  bacilli. 
Whether  the  metallic  bismuth  or  the  liberation  of  the 
nitric  acid  from  the  subnitrate  is  the  chemotactic  factor, 
I  do  not  know,  but  Baer's  theory  appeals  to  me  as  the 
most  plausible.  The  chemotactic  property  of  the  paste 
is,  then,  considered  the  prime  factor. 

The  mechanical  action  of  the  paste — namely,  the  dis- 
tention of  the  collapsed  sinuses,  and  filling  them  with  a 
smooth,  aseptic  substance,  instead  of  allowing  acrid  se- 
cretions to  bathe  their  walls — is,  no  doubt,  a  favorable 
factor.     The   change  in   the  granulating   surfaces  indi- 


THERAPEUTIC  EFFECTS.  59 

cates  that  the  paste  is  an  excellent  aid  for  the  formation 
of  healthy  granulations.  It  serves  as  a  support  for  the 
formation  of  new  granulations,  which  become  so  large 
that  they  bulge  out  from  the  sinus  openings.  The  paste 
is  displaced  by  the  rapid  growth  of  these  granulations, 
and  escapes  through  the  external  openings. 

Very  often  the  granulations  are  covered  with  a  whitish 
membrane  similar  to  the  diphtheritic  membrane,  which, 
when  peeled  off,  leaves  a  perfectly  clean  surface  under- 
neath. This  coating  is  a  deposit  of  fibrin  which  under- 
goes organization.  "We  have  examined  sections  of  this 
membrane  and  found  it  infiltrated  with  leucocytes  and 
some  elongated  connective  tissue  cells. 

Another  factor  to  which  I  have  referred  in  my  former 
publications  is,  no  doubt,  of  some,  but  only  secondary, 
importance.  The  exposure  of  tuberculous  disease  to  the 
x-rays  is  known  to  be  of  great  benefit,  and  many  remark- 
able cures  are  recorded  in  the  literature  to  support  this. 
It  is  a  known  fact  that  bismuth  subnitrate,  as  well  as 
vaselin,  when  exposed  to  the  x-rays,  will  become  radio- 
active, and  will  retain  this  radioactivity  for  several 
hours.  It  seems  reasonable  to  me  that  this  property  may 
accelerate  the  therapeutic  action  of  the  paste.  1  have 
taken  advantage  of  this  principle  and  exposed  the  most 
refractory  cases  to  the  action  of  the  x-rays  at  intervals  of 
three  days,  and  am  convinced  that  their  action  has  beeu 
beneficial.  It  must  be  admitted  that  the  exposure  to  the 
x-rays  is  not  essential,  since  many  surgeons  have  recorded 
excellent  reports  without  them. 

At  present  I  consider  these  three  factors  as  the  princi- 
pal agents  in  the  therapeutic  action  of  the  paste: 

1.  The  chemotactic  quality  of  the  paste,  which  induces 
the  bactericidal  action. 

2.  The  mechanical  action. 

3.  The  exposure  of  the  injected  sinuses  to  the  x-rays. 


CHAPTER  VI. 

TREATMENT  OF  SINUSES  DUE  TO  SPONDYLITIS. 

The  extreme  frequency  of  Pott's  disease  and  its 
serious  consequences  make  it  imperative  that  the  physi- 
cian should  possess  definite  knowledge  of  its  causes,  de- 
velopment, and  complications,  and  be  also  informed 
about  the  most  advanced  and  safest  methods  of  treat- 
ment. The  physician's  action  in  a  given  case  of  Pott's 
disease  is  of  the  utmost  importance  for  the  life  of  the 
patient.  There  is  hardly  another  disease  to  which  we 
can  ascribe  a  larger  percentage  of  therapeutic  failures 
than  spondylitis,  in  spite  of  the  fact  that  we  possess  the 
means  of  saving  nearly  every  case. 

This  disease  is  essentially  a  tuberculosis.  This  in  it- 
self relieves  us  of  the  task  of  searching  for  its  cause. 
We  know  from  the  researches  of  many  scientists  (espe- 
cially Koch)  that  without  the  tubercle  bacillus  there  can 
be  no  tuberculosis,  and  thus  we  are  certain  that  this 
germ  has  somehow  found  its  way  into  the  body  of  the 
affected  individual. 

The  question  must,  however,  be  answered,  Will  the 
presence  of  the  bacillus  alone  cause  the  disease  in  bony 
structures'?  The  impression  predominates  that  it  re- 
quires a  trauma  to  precipitate  a  tuberculous  disease  with- 
in the  bones  or  joints  by  producing  a  locus  minoris  re- 
sistentise,  and  thus  permit  the  tubercle  bacilli  circulating 
in  the  blood  to  get  a  foothold.  Clinical  facts  support  this 
view,  but  the  question  is  not  fully  answered.  Was  the 
injured  part  perfectly  healthy  before  the  injury?  Is  it 
not   possible   that   through    the   trauma    a    preexisting 

60 


SINUSES  DUE  TO  SPONDYLITIS.  61 

latent,  encapsulated  tuberculous  focus  ruptured,  and  the 
bacilli  thus  liberated  found  in  the  traumatized  bone  a 
suitable  soil  for  rapid  development? 

This  latter  view  was  propounded  by  Friedrich1  and 
Hansel,2  and  has  many  plausible  facts  to  support  it. 
The  bones  are,  as  a  rule,  infected  through  the  hematog- 
enous route,  unless  the  disease  extends  by  continuity 
from  a  neighboring  joint  (Konig),  but  it  is  also  possible 
to  spread  through  the  lymphatic  channels.  Usually  the 
infection  takes  place  through  bacilli-carrying  emboli, 
which  lodge  in  the  smallest  branches  of  the  arteries  and 
there  set  up  the  tuberculous  infection  (Miiller). 

This,  to  a  degree,  explains  why  the  disease  selects  for 
its  victims  small  children.  The  rich  and  many-branched 
arrangement  of  the  blood  vessels  in  the  young  growing- 
bones  favors  the  lodgment  of  emboli,  and  thus  the  be- 
ginning of  the  disease.  The  source  of  the  bacilli  is  usu- 
ally a  primary  tuberculosis  of  the  lymph  glands,  which 
in  most  cases  can  be  clinically  demonstrated. 

It  is  important  to  know  whether  in  a  given  case  the 
localized  tuberculosis  in  the  spine  is  the  only  part  of 
the  body  affected.  Is  there  such  disease  as  primary 
tuberculosis  of  the  osseous  system?  To  this  question 
Professor  Konig"  answers,  "Yes."  By  very  thorough 
investigation  of  67  subjects  who,  during  life,  were  af- 
flicted with  joint  tuberculosis,  he  found  14  of  the  67,  or 
21  percent,  had  no  other  tuberculous  infection  than  that 
of  the  joints.  This  indicates  that  osseous  tuberculosis 
may  be  primary,  but  it  likewise  shows  that  79  percent  of 
cases  have  multiple  foci,  and  thus  we  must  suspect  in  at 
least  four-fifths  of  all  cases  tuberculous  foci  in  other 
parts  of  the  body  to  coexist. 


xFriedrich:  Experimentale     Beitrage     zur     Tubereulose. — Deutsche      Zeit- 
6chrift  fur  Chirurgie,  bd.  53,  s.  512. 

2  Hansel:  Ueoer  Trauma   des   Gelenke. — Beitrage  zur   Klinik   der  Tubercu- 
lose.  bd.  28,   s.  659. 

3  Konig:  Die  Tubereulose  der  Menschlichen  Gelenke.  1906. 


62  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

This  tuberculous  infection  within  the  bodies  of  the  ver- 
tebrae causes  a  gradual  destruction  of  the  same,  so  that 
a  gap  on  the  anterior  portion  is  soon  established.  What 
is  the  result  I  The  body  weight  causes  a  collapse  of  the 
column  at  the  weak  point,  and  a  more  or  less  pointed  pro- 
jection backwards  results,  which  is  called  kyphus.  If 
the  body  weight  is  not  supported  by  artificial  means,  the 
continuous  weight  upon  the  diseased  and  friable  ver- 
tebra will  increase  the  deformity,  and  change  the  shape 
of  not  only  the  spine,  but  also  the  chest  and  the  relation 
of  its  viscera. 

Fortunately,  in  all  tuberculous  infections  there  is  a 
natural  tendency  to  repair.  The  gap  produced  by  the 
destruction  of  bone  is  soon  filled  with  newly-formed 
bone  tissue,  although  not  of  normal  texture,  but  solid 
enough  to  establish  a  strong  splint  for  the  weight-bear- 
ing spine. 

The  majority  of  surgeons  consider  the  formation  of  a 
kyphus  as  a  necessary  evil  essential  to  a  cure.  This 
view  is  hotly  opposed  by  Calot,1  who  for  years  has  advo- 
cated a  method  for  its  prevention,  and,  even  when  the 
kyphus  has  already  formed,  he  claims  the  spinal  column 
may  be  straightened  by  proper  redressment.  He  demon- 
strates the  feasibility  and  success  of  this  treatment  by 
most  convincing  illustrations. 

The  complications  of  spondylitis  are  abscess,  fistulae, 
paralysis,  and  deformities.  In  this  chapter  we  shall  con- 
sider only  one  of  these  complications — namely,  the  result- 
ing sinuses. 

We  have  already  described  the  process  of  formation 
of  sinuses.  We  know  that  they  are  the  shriveled  abscess 
walls  leading  to  the  original  focus  of  disease.  The  cold 
abscesses    following    spondylitis    have    three    favorable 


1  Calot:  Die  Behandlung  der  Tuberculosen  Wirbelentzundung,  1907. 


SINUSES  DUE  TO  SPONDYLITIS.  63 

locations  for  their  rupture.  In  children  they  open  most 
frequently  into  Scarpa's  triangle,  or  above  Poupart's 
ligament;  in  adults  they  usually  select  the  lumbar  region. 
The  dorsal  vertebrai  are  most  frequently  affected.  Jn 
538  cases,  reported  by  Dollinger,  63  were  in  the  cervical 
region,  321  in  the  dorsal,  and  154  in  the  lumbar  region. 
The  disease  is  not  frequent  before  the  second  year;  50 
percent  of  all  cases,  however,  occur  between  the  third 
and  sixth  years,  and  the  disease  rarely  starts  after  the 
twentieth  year. 

Spondylitis  occurs  oftener  in  males  than  in  females. 
In  Hoffa's  analysis  of  3,795  cases,1  2,045  were  males  and 
1,750  females.  Compared  in  frequency  to  tuberculosis 
of  other  joints,  it  stands  first.  At  the  Children's  Hospi- 
tal in  Boston,  of  a  total  of  5,950  cases  of  joint  tubercu- 
losis, 2,867  affected  the  spine. 

For  the  purpose  of  elucidating  the  finer  points  in  the 
treatment  with  bismuth  paste,  the  following  types  are 
cited : 

Example  1.  Spondylitis  of  Tenth  Dorsal,  with  Supraclavicular  and 
Lumbar  Sinuses. — This  case  is  cited  to  show  that  in  extreme  cases  the 
sinuses  may  open  at  a  great  distance  from  their  sources,  in  regions 
where  their  communication  is  not  expected.  This  little  girl,  shown 
in  Fig.  12,  is  12  years  old,  and  had,  as  a  result  of  a  spondylitis  of  five 
years'  standing,  three  sinuses — one  in  the  lumbar  region,  one  near  the 
eighth  dorsal  spinous  process,  and  one  in  the  supraclavicular  region, 
all  on  the  right  side  of  her  body.  The  suppuration  was  very  profuse  for 
years,  with  a  varying  daily  temperature  of  from  98°  to  102°,  with  ex- 
treme emaciation  and  amyloid  degeneration  of  the  organs.  The  supra- 
clavicular sinus  was  thought  to  be  due  to  a  broken-down  tubercular 
gland  of  the  neck  until  the  first  bismuth  injection,  in  July,  1909,  proved 
that  all  three  sinuses  communicated.  The  paste  was  injected  in  the 
dorsal  sinus,  and  escaped  through  the  other  two  openings,  the  lumbar 
as  well  as  the  supraclavicular.  The  sinus  in  the  neck  closed  after  the 
first  injection,  but  the  two  others  persisted  in  discharging.  Although 
the  quantity  of  pus  was  diminished  and  its  character  changed  to  a 
seropurulent  fluid,  the  prognosis  in  this  case  is,  in  view  of  the  extreme 
marasmus,  very  unfavorable. 


1Hoffa:  Orthopedic  Surgery,   5th  edition,  p.  239. 


64 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS 


The  radiograph  (Fig.  13)  was  taken  after  the  sinus  in  the  neck  wa 
closed,  and  therefore  shows  the  paste  to  reach  only  into  the  tenth  dor- 
sal vertebra. 

Example  2.  Spondylitis,  Sixteen  Years'  Duration;  Sinus  Healed  with 
Three  Injections. — J.  C,  aged  18,  with  a  tainted  family  history  as  to 
tuberculosis,  was  a  strong  baby  until  he  had  spinal  meningitis  when  18 
months  old.  A  year  later  a  deformity  of  the  spine,  with  all  the  symp- 
toms of  tubercular  spondylitis,  developed.     A  psoas  abscess  formed  and 


Fig.   12.      Spondylitis  of  the  tenth  dorsal  vertebra,  with  communicating  sinuses 
in  supraclavicular  and  lumbar  region. 


opened  in  the  right  Scarpa's  triangle.  An  irritating  pus  discharge  has 
persisted  for  the  past  twelve  years.  I  made  the  first  injection  of  bis- 
muth paste  in  this  case  in  May,  1909,  and  the  radiograph  taken  (Fig. 
14)  disclosed  a  most  tortuous  fistula,  the  paste  having  reached  the  seat 
of  the  focus  in  the  vertebra,  and  from  there  being  forced  into  an 
existing  channel  on  the  opposite  side,  which  had  its  blind  end  about 
two  inches  above  the  hip  joint.  There  was  not  the  slightest  suspicion 
that  this  left  sinus  existed  until  it  was  discovered  by  means  of  the 
paste  injections  and  radiography. 


SINUSES  DUE  TO  SPONDYLITIS. 


65 


The  most  pleasing  phase  of  this  case,  however,  was  the  surprii  Ing 
therapeutic  effect  resulting  from  the  bismuth  paste.  With  only  two 
subsequent  injections  the  sinus  closed,  the  patient  gaining  fourteen 
pounds  in  weight  in  four  weeks. 


Fig.   13.      Spondylitis   of   tenth  vertebra,    showing   course   of   sinus,   opening    in 
lumbar  region  at  point  of  black  dot,  and  then  downward  course  into  the  pelvis. 


This  case  teaches  several  points: 

First,  it  illustrates  the  fact  that  sinuses  are  formed  by 
contraction  of  the  abscess  cavity. 

Second,  that  even  after  twelve  years'  suppuration  we 
may  obtain  a  cure  with  a  simple  injection  of  the  bismuth 
paste. 

Third,  that  the  absorption  of  small  quantities  of  paste 


66 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


will  not  cause  any  symptoms  of  intoxication, 
case  all  of  the  injected  paste  was  absorbed. 


In  this 


Example  3.  Bilateral  Psoas  Abscess  Without  Destruction  of  Ver- 
tebrae.— Miss  M.  K.,  aged  18,  was  in  perfect  health  until  two  years  ago. 
September,  1907,  she  fell  and  injured  the  tip  of  her  coccyx.  Thereafter 
she  was  constantly  ill,  and  in  December,   1908,  an   abscess  developed 


Fig.   14.     Sinus    following    psoas    abscess,    sixteen    years'    duration    (since    in- 
fancy).    Closed  after  third  injection  of  bismuth  paste. 


above  the  right  Poupart's  ligament.  Two  weeks  later  the  abscess 
was  lanced  by  the  attending  physician  and  drainage  established.  In 
January,  1909,  another  abscess  formed  on  the  left  side,  in  relatively 
the  same  region,  and  this  was  also  incised  and  drained.  Both  result- 
ing sinuses  persisted  in  discharging  profusely,  so  much  so  that  in 
order  to  maintain  a  semblance  of  cleanliness  the  dressings  had  to  be 
changed  two  to  three  times  daily.    Radiographs  of  the  spine  failed  to 


SINUSKS  Dl!  K  TO  SPONDYLITIS. 


67 


disclose  any  destruction  of  vertebrae,  and  a  radiograph  taken  after 
an  injection  of  bismuth  paste  furnished  a  remarkable  picture.  (Fig. 
15.)  The  two  abscess  cavities  are  shown  to  be  symmetrical,  both  tri- 
angular in  form,  having  sharp  borders,  unlike  those  following  psoas 
abscess.  The  diagnosis  was  for  a  time  doubtful,  but  we  have  discov- 
ered that  the  intervertebral  disc  between  the  third  and  fourth  lumbar 
vertebrae  was  missing,  and  in  the  absence  of  any  other  finding  we 
concluded  that  in  this  space  lay  the  focus  of  infection.  The  patient 
is  still  under  treatment,  and,  while  her  condition  is  much  improved, 
the  discharge  greatly  diminished,  and  one  sinus  already  closed,  the 
final  outcome  is  still  uncertain. 


Fig.  15.     Bilateral  psoas  < 
ing  above  Poupart's  ligaments 


abscess  without  destruction  of  vertebrae.     Each  open- 

3. 


The  quantities  of  paste  required  for  injection  of  the 
sinuses  following  spondylitis  are  usually  very  small, 
especially  when  the  sinus  has  existed  many  years,  such 
as  example  2  here  cited,  which  had  existed  twelve  years, 
where  only  half  an  ounce  of  paste  was  sufficient  to  fill 
this  long,  narrow  channel.  In  recent  cases  the  abscess 
cavities  have  not  yet  shriveled  down  to  narrow  channels, 


68  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

and  thus  may  hold  large  quantities,  and  can,  on  account 
of  the  softness  of  their  walls,  be  overdistended.  For  this 
reason  I  often  use  a  10-percent  bismuth  paste  to  prevent 
toxic  effect  from  absorption. 

In  our  series  of  cases  of  spondylitis  with  sinuses,  60 
percent  have  healed  subsequent  to  the  injections.  The 
remarkable  fact  is  that  the  cases  in  which  we  least  ex- 
pected a  cure — namely,  those  that  had  existed  for  the 
longest  period — proved  to  be  most  favorable,  and  those 
of  more  recent  origin  were  refractory. 

I  have  reported1  a  case  of  spondylitis  in  a  lady,  aged 
51,  with  sinuses  in  right  and  left  lumbar  regions,  in  which 
rubber  drains  had  been  kept  for  thirteen  and  eight  years 
respectively,  and  nevertheless  it  took  only  two  months  for 
their  permanent  closure. 

I  must,  however,  warn  against  the  premature  declara- 
tion of  a  cure.  There  is  no  disease  in  which  a  cure  is 
more  often  only  apparent  than  tuberculous  disease  of  the 
bones  or  joints.  Recurrence  or  reopening  of  the  sinuses, 
even  after  months,  has  taken  place  in  a  few  cases,  and 
thus  we  must  be  conservative  and  wait  for  a  reasonable 
length  of  time  before  we  assure  our  patient  that  he  is 
permanently  cured. 

It  must,  however,  be  stated  that,  in  patients  who  lived 
through  the  complications  of  abscess  and  sinuses  and 
were  finally  cured,  recurrence  was  much  less  frequent 
than  in  the  cases  in  which  the  disease  was  checked  in  its 
incipiency. 


!Beck:  Eeitriige  zur  Klinisehe  Chirurgie,  1909,  bd.  62,  h.  2. 


CHAPTER  VII. 

TREATMENT   OF  SINUSES  FOLLOWING  OSTEO- 
MYELITIS AND  JOINT  DISEASES. 

Two  principal  varieties  of  osteomyelitis  and  arthritis 
are  recognized — those  of  pyogenic  and  those  of  tubercu- 
lous origin. 

The  pyogenic  or  nontuberculous  osteomyelitis  origi- 
nates in  three  different  ways:  first,  in  consequence  of  in- 
juries, such  as  fractures,  in  which  the  bones  were  ex- 
posed or  denuded  of  their  periosteum;  second,  by  exten- 
sion of  pyogenic  infection  from  soft  structures,  such  as 
phlegmon;  and,  third,  through  the  circulation.  All 
varieties  of  pus-producing  microorganisms  are  liable  to 
cause  this  form  of  infection. 

In  ectogenous  infections  the  staphylococcus  pyogenes 
aureus  and  streptococcus  are  the  usual  invaders,  while 
through  the  hematogenous  route  the  mixed  infections  of 
the  staphylococcus  pyogenes  albus  and  the  streptococcus 
pyogenes  lead  in  frequency,  and  next  in  frequency  occur 
the  pneumococcus,  the  gonococcus,  the  bacillus  typhosus, 
the  colon  bacillus,  and  bacillus  influenza?.  If  the  infec- 
tion follows  external  injury,  the  periosteum  is  first  at- 
tacked, it  being  lifted  from  the  bone,  and  thus  the  dis- 
ease may  reach  the  bone  marrow. 

The  nontubercular  infection  usually  starts  in  the  bone 
marrow  of  the  long  bones ;  less  frequently  in  the  cortical 
substance  or  the  periosteum.  From  this  primary  focus 
it  may  spread  in  all  directions,  and  may  even  break 
through  the  epiphysis  into  a  joint,  but  most  frequently  it 
spreads  through  the  Haversian  canals  toward  the  peri- 

69 


70  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


Pig.   16.     Sinuses  from  nontuberculous  osteomyelitis. 


SINUSES  FOLLOWING  OTHER  DISEASES.  71 

osteum,  and  causes  a  suppurative  periostitis.  The  accu 
mulation  of  pus  will  separate  the  periosteum  from  the 
bone  shaft,  deprive  the  underlying  section  of  bone  of  its 
nutrition,  and  lead  to  its  necrosis.  A  sequestrum  is  thus 
formed.  This  necrotic  bone,  now  entirely  detached,  acts 
as  a  foreign  body.  Nature  tries  to  cither  eliminate  or  en- 
capsulate it.  A  liquefaction  or  crumbling  of  this  bone 
will  take  place  until  only  the  hardest  of  its  structure — a 
mere  shell,  perforated,  grooved,  with  edges  sharp  and  ir- 
regular— will  remain.  Such  is  the  characteristic  seques- 
trum of  pyogenic  osteomyelitis. 

During  the  time  of  this  destructive  process  a  reactive 
osteoplastic  inflammation  takes  place,  in  which  the  peri- 
osteum takes  the  principal  part.  This  osteoplastic  proc- 
ess surrounds  the  dead  bone  with  a  strong  casing,  and 
at  the  same  time  strengthens  the  shaft  of  the  diseased 
bone.  As  a  result  of  the  disintegration  of  the  bone  and 
the  suppuration  of  the  tissues,  an  abscess  is  formed.  At 
times  the  pressure  of  the  pus  breaks  down  the  barriers, 
the  abscess  is  ruptured  toward  the  outside,  and  a  sinus  is 
formed. 

The  following  case  is  typical  of  the  facts  just  men- 
tioned : 

Nontubercular  Osteomyelitis  of  Humerus. — G.  W.,  a  boy,  aged  13. 
was  brought  to  Dr.  Carl  Beck  for  operation  in  August,  1909.  He  had 
suffered  from  a  suppurating  sinus  of  his  arm  for  over  a  year.  Two 
operations  had  failed  to  cure  the  condition. 

Examination  revealed  a  very  much  thickened  bone  of  irregular  con- 
tour, extending  from  the  head  of  the  humerus  to  about  the  middle  of 
the  arm.  On  the  external  surface  of  the  arm  was  a  sinus,  and  a 
large  scar  as  evidence  of  a  former  operation.  (Fig.  16.)  The  first 
radiograph  (Fig.  17)  taken  shows  the  presence  of  several  large  se- 
questra, imbedded  in  a  mass  of  dense  tissue.  This  skiagraph  shows 
distinctly  the  darker  shadows  of  the  sequestra  and  a  brighter  zone 
around  them,  indicating  a  layer  of  granulations,  in  which  they  are 
imbedded.  Another  darker  shadow  outside  of  the  light  zone  indicates 
the  layers  of  reactive  ostitis — new  formation  of  bone. 


72  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


Fig.  17.     Radiograph  of  humerus  showing  sequestra,     (Case  shown  in  Fig.  16.) 


SINUSES  FOLLOWING  OTHER  DISEASES. 


Fig.   17  A.      Diagrammatic  illustration  of  Fig.  17. 


Fig.   18.     Three  of  the  sequestra  removed  from  humerus.     (Case  shown  in  Fig.  16.) 


74  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


Fig.  19.     Bismuth   paste   injected    into    cavity    after   sequestra   were    removed. 
(Case  shown  in  Fig.  16.) 


SINUSES  FOLLOWING  OTHER  DISEASES. 


70 


Fig.  19  A.      Diagrammatic  illustration  of  Fig.  19. 


76  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


Pig.   20.     Bismuth,   paste   remaining   after   sinuses   were   closed.      (Case  shown 
in  Fig.  16.) 


SINUSES  FOLLOWING  OTHER  DISEASES.  77 


Fig.  21.     Complete  closure   of   sinuses   and  perfect   restoration   of   function    of 
arm.     (Case  shown  in  Fig.  16.) 


78 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


The  accompanying  tracings  explain  the  various  pathologic  changes 
in  the  humerus  shaft. 

An  operation  was  performed  by  Dr.  Carl  Beck,  seven  sequestra 
(Fig.  18)  being  removed,  and  the  cavity  packed  with  gauze.  Twenty- 
four  hours  later  the  gauze  was  removed  and  the  cavity  filled  with 
bismuth  paste.     A  second  radiograph  (Fig.  19)  was  taken,  which  shows 


Pig.  22. 
tic  sclerosis. 


Typhoid  osteomyelitis  of  tibia.     A,  granulating  cavity  ;  B,  hyperplas- 


that  all  sequestra  had  been  removed,  and  that  the  entire  cavity  had 
been  filled  with  the  paste,  leaving  only  the  lighter  zone  of  the  granu- 
lation tissue. 

With  few  additional  injections  of  the  paste  the  cavity  has  entirely 
filled  with  healthy  granulations  and  new  formation  of  bone  (Fig.  20) ; 
sinuses  have  closed  within  three  weeks  after  the  operation,  and  re- 
mained so. 


SINUSES  FOLLOWING  OTHER  DISEASES.  79 

The  boy  now  has  perfect  motion  of  his  arm,  as  shown  in  Fig.  21, 
and  sufficient  strength  to  do  ordinary  hard  work. 

A  typical  case  of  typhoid  osteomyelitis  of  the  tibia  is  shown  in  a 
radiograph.  (Fig.  22.)  The  disease  in  the  bone  appeared  four  months 
after  the  typhoid  fever  subsided.  The  pus  contained  typhoid  bacilli. 
The  small  area  of  infection  is  filled  with  granulation  tissue  (A),  and 
the  entire  diseased  process  is  surrounded  by  a  layer  of  hyperplastic 
sclerosis  (B),  which  acted  as  a  barrier  against  spreading. 


Pyogenic  Arthritis. — The  nontubercular  infection  of 
joints  has  the  same  etiology  as  that  of  the  bones,  and  may 
likewise  occur  through  the  hematogenous  route  as  a  con- 
sequence of  an  acute  general  infection,  such  as  scarlet 
fever,  diphtheria,  pneumonia,  gonorrhea,  erysipelas,  and 
meningitis. 

The  synovial  membrane  is  the  structure  first  attacked. 
In  consequence  of  its  infection  an  exudate  will  at  once 
be  thrown  out  into  the  joint  cavity.  This  exudate  may 
be  serous,  serofibrinous,  or  from  the  start  purulent,  de- 
pending upon  the  virulence  or  type  of  the  infective 
organism.  The  serous  or  serofibrinous  variety  repre- 
sents the  milder  forms  of  infection,  while  the  severer 
forms  will,  from  the  start,  cause  a  suppuration  within 
the  joint,  and  may  either  destroy  the  same  or  cause  a 
general  septicemia  or  pyemia,  unless  proper  surgical 
measures  are  taken. 

In  either  the  acute  or  chronic  pyogenic  arthritis  the  ac- 
cumulation of  pus  within  the  joint  may  eventually  lead 
to  a  sinus  formation.  The  pus  may  reach  the  surface 
either  by  spontaneous  rupture  of  the  joint  or  through 
surgical  intervention. 

Tuberculous  Osteomyelitis. — Except  for  anatomical  dif- 
ferences, the  formation  of  sinuses  from  tuberculous  osteo- 
myelitis is  the  same  as  that  described  in  the  chapter  on 
spondylitis.  The  primary  infection  likewise  takes  place 
through  the  circulation  or  the  lymphatics,  and  then  ex- 


80 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


tends  to  neighboring  structures.  The  predominating 
opinion  is  that  in  the  tuberculous  type  the  epiphyses  are 
in  the  vast  majority  of  cases  the  primary  focus  of  the  in- 


Epiphysial  /  V    V/.^fcWu,. 
arteries  \^ff  j££ 

Metaphysial  /V  \Awt 


Metaphysial 

arteries   "~'i4      y-'j  \\$ 

Epiphysial     t/p^—c^        '       •  t 
arteries     [pC^--   *-£ 

Pig.  23. 

Figs.  23,  24.      Blood  supply  in  bones  of  infant,  showing  subdivisions  of  nutrient 
artery  in  metaphysial  line.      (Lexer.) 


Epiphysial 
arteries 


Fig.  24. 


fection,  and  that  from  there  the  disease  extends  into  the 
joint  proper.  Professor  Konig  has,  however,  pointed 
out  that  primary  synovial  tuberculosis  is  far  more  fre- 
quent than  is  supposed,  and  his  experience  is  supported 


SINUSES  FOLLOWING  OTJJ.KK  DISEASES.  81 

by  Lexer,1  who  states  that  the  synovial  form  is  at  least 
as  often  primary  as  the  osseous  form. 

In  the  osseous  form  the  disease  is,  no  doubt,  of  em- 
bolic origin.  A  study  of  the  blood  supply  in  the  bones 
of  growing  children  (Figs.  23,  24)  teaches  us  why  this 
disease  selects  the  ends  of  the  bones  of  young  individuals. 
The  smallest  subdivisions  of  the  nutrient  artery  take 
place  at  the  metaphysial  end,  and  the  epiphysial  arter- 
ies enter  from  all  sides  and  meet  in  the  center  of  the 
epiphysis.  Small  triangular  infarcts,  when  present,  are 
due  to  blocking  of  one  of  these  end  arteries  with  bacilli- 
carrying  emboli,  and  from  this  focus  the  disease  spreads 
into  neighboring  areas. 

This  primary  infection  causes  an  inflammatory  reac- 
tion, with  an  area  of  infiltration,  gradual  formation  of 
tubercles,  and  finally  a  cheesy  degeneration  of  its  center. 
The  cancellous  bone  tissue  is  gradually  destroyed,  and  a 
sequestrum  of  the  harder  portions  of  the  bone  may  re- 
main. The  tuberculous  sequestrum  has  certain  charac- 
teristics. It  is  usually  a  small  roundish  or  oblong  body, 
resembling  a  rough  gallstone,  seldom  reaching  the  size  of 
a  walnut,  while  the  sequestrum  in  the  nontuberculous 
form  is  usually  flat  and  zigzag-edged. 

Surrounding  this  diseased  area  we  find  a  zone  of  new 
bone  formation  (periostitis  ossificans),  which  forms  a 
capsule  around  the  sequestrum  and  the  broken-down 
bone  (Knochensand — bone  sand).  The  process  is  liable 
to  heal  spontaneously.  If,  however,  the  disease  has  a 
tendency  to  further  invasion,  the  limiting  pyogenic  mem- 
brane, or  the  osteosclerosis,  will  not  form,  but  instead  a 
diffuse  tuberculous  ostitis  will  take  place.  In  this  pro- 
gressive form  the  tuberculous  disease  may  spread  up- 
ward and  affect  the  entire  shaft  of  the  long  bone,  or  it 

1  Lexer:  Allgemeine  Chirurgie,  1910,  bd.  2,  s.  378. 


82  BISMUTH  PASTE  IN  dHRONIC  SUPPURATIONS. 

may  extend  to  and  break  into  the  joint,  and  also  affect 
the  para-articular  soft  tissues.  An  abscess  will  then 
usually  result,  which  may  undermine  the  tissues  and 
break  through  the  skin  in  one  or  more  places,  and  thus 
the  tuberculous  sinuses  are  formed. 

Tuberculous  Arthritis. — "When  this  disease  starts  in  the 
joint,  the  tubercle  bacilli  are  primarily  deposited  in  the 
capillaries  of  the  synovia,  and  form  miliary  tubercles  in 
this  lining  membrane.  Inflammatory  reaction  is  mani- 
fested by  a  serous  or  serofibrinous  exudate  and  the  forma- 
tion of  tuberculous  granulations. 

In  the  milder  forms  or  in  the  beginning  the  exudate 
is  of  serous  character  (hydrops  articularis  tuberculosis, 
Konig)  or  may  contain  white  flakes,  which  indicate  an 
addition  of  fibrin  to  the  fluid  (hydrops  fibrinosus,  Konig). 
In  the  former  the  fluid  is  gradually  absorbed;  in  the  lat- 
ter type  the  fibrin  is  deposited  on  the  joint  surfaces,  and, 
through  organization,  causes  their  thickening,  sometimes 
the  formation  of  a  villous  growth  (Fig.  25),  or  of  free 
floating  bodies.  These  free  floating  bodies,  also  called 
rice  bodies  (Fig.  26)  (corpora  oryzoidea),  are  always 
the  result  of  a  tuberculous  infection,  as  they  contain  the 
tubercle  bacilli,  and  when  inoculated  into  guinea  pigs 
will  invariably  produce  tuberculosis. 

In  the  severe  forms  the  disease  may  still  be  arrested 
and  the  granulations  undergo  cicatrization.  If  cicatriza- 
tion takes  place,  the  synovia  is  studded  with  tubercles, 
which  are  covered  by  a  pale,  grayish-red,  granular  coat- 
ing; if  the  disease  progresses,  the  synovia  is  covered  with 
a  spongy  mass  of  soft  and  mushy  granulation.  This  con- 
dition is  called  fungus  (Gliedschwamm),  and  causes  a 
pseudo-fluctuation,  and  is  therefore  often  mistaken  for 
an  abscess.  In  this  latter  form  the  parasynovial  struc- 
tures become  edematous  and  swell,  so  as  to  put  the  over- 


SINUSES  FOLLOWING  OTHEK  DISLASLS.  80 

lying  skin  upon  a  tension,  thus  producing  an  anemic, 
"shining"  swelling  of  the  joint,  which  in  the  knee  is 
familiarly  known  as  tumor  albus. 

In  the  most  severe  form  the  masses  of  granulations 
within  the  joint  undergo  cheesy  degeneration  and  small 


Pig.   25.     Villous  growth  of  tuberculous  knee  joint.      (Konig.) 

foci  of  suppuration.  The  latter  are  the  forerunners  of 
the  abscess  formation.  Their  number  increases  until 
they  coalesce  and  form  the  "abscess."  When  the  ab- 
scess is  under  great  tension,  the  surrounding  structures 
become  undermined  and  pus  will  work  its  way  toward 
the  skin  surface,  and  the  abscess  may  finally  rupture. 


84  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

The  disease  may  even  lead  to  the  destruction  of  the  car- 
tilages and  the  underlying  bone  surfaces,  so  that  the  en- 
tire joint  is  transformed  into  a  mass  of  debris. 

The  clinical  course  of  joint  tuberculosis  is  variable,  de- 
pending upon  age  of  the  patient,  his  resistance,  and  the 
joints  affected.  In  general,  the  disease  starts  very  in- 
sidiously, and  the  progress  is  gradual.     Only  in  little 


Fig.  26.      Rice  bodies  from  tuberculous  joint.     (Beck.) 

babies  do  we  encounter  an  acute  onset  of  this  disease. 
The  diagnosis  in  its  incipiency  is  very  difficult,  and  many 
cases  are  treated  weeks  and  months  for  rheumatism, 
sciatica,  neuralgia,  etc.,  before  any  characteristic  symp- 
toms arise.  The  usual  forerunners  are  weakness  in  the 
affected  limb,  frequent  lancinating  pains,  until  the  signs 
of  the  joint  affection  are  manifest.     When  the  character- 


SINUSES  FOLLOWING  OTHER  DISEASES.  85 

istic  swelling  and  fixation  of  the  joint  are  jn'esent,  the 
diagnosis  is  easily  established.  A  radiograph  in  doubt- 
ful cases  is  a  most  valuable  aid.  The  early  diagnosis  is, 
of  course,  the  salvation  of  the  individual,  because  we 
possess  the  means  of  checking  the  disease  only  in  its  be- 
ginning. 

Should  an  abscess  form  in  spite  of  our  efforts  to  pre- 
vent it,  we  may  still  prevent  the  formation  of  a  sinus  by 
proper  conservative  treatment,  of  which  I  shall  speak  in 
another  chapter.  When,  however,  the  sinus  is  already 
present,  then  the  treatment  with  bismuth  paste  will  be 
of  service. 

Sinuses  Following  Hip  Joint  Disease. 

Next  in  frequency  to  spondylitis,  the  hip  is  affected. 
Of  5,950  cases  of  joint  tuberculosis  treated  at  the  Chil- 
dren's Hospital  in  Boston,  2,281  affected  the  hip  and 
2,867  the  spine.  In  our  series  of  cases,  treated  at  the 
North  Chicago  Hospital  during  the  past  four  years,  the 
relative  frequency  of  these  two  conditions  was  41  cases  of 
hip  joint  disease  to  34  cases  of  spondylitis.  These  num- 
bers, however,  include  only  the  cases  in  which  sinuses 
were  present.  In  the  cases  without  sinuses  the  relative 
proportion  was  equal,  11  cases  of  each  having  come  under 
our  care.  In  only  three  instances  did  spondylitis  and  hip 
joint  disease  coexist. 

In  this  series  of  41  cases  of  hip  joint  disease  with  sinuses 
the  right  hip  was  affected  in  26,  the  left  in  only  15  cases, 
none  being  bilateral.  This  disproportion  seems  to  us 
more  than  accidental,  as  this  same  relative  frequency 
has  kept  up  each  year  since  we  first  observed  it. 

Shortening  of  the  affected  limb  existed  in  practically 
all  cases,  since  the  head  of  the  femur  was  destroyed  in 
nearly  every  case  where  the  disease  was  so  extensive  as 


86  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

to  progress  to  sinus  formation.  In  one  case  the  shorten- 
ing amounted  to  eight  inches.  In  two  cases  there  was  no 
ankylosis,  although  the  head  of  the  femur  was  destroyed. 

It  is  easy  to  make  a  correct  diagnosis  of  hip  joint  dis- 
ease when  sinuses  are  already  present.  I  have  neverthe- 
less encountered  and  cited  in  Chapter  IV  cases  where 
sacral  tuberculosis  was  mistaken  for  hip  joint  disease 
because  the  abscess  happened  to  open  directly  over  the 
hip. 

Three  principal  complications  result  from  hip  joint  dis- 
ease— the  shortening,  the  ankylosis,  and  sinuses.  I  shall 
here  consider  only  the  latter. 

The  number  of  sinuses  which  are  liable  to  result  from 
a  tuberculous  coxitis  may  vary  extremely.  In  our  series 
of  41  cases, 

12  cases  had  1  sinus. 

8  cases  had  2  sinuses. 

9  cases  had  3  sinuses. 
1  case  had  4  sinuses. 

3  cases  had  5  sinuses. 

4  cases  had  6  sinuses. 

1  case  had  8  sinuses. 

2  cases  had  16  sinuses. 
1  case  had  20  sinuses. 

The  sinuses  usually  open  near  the  trochanter  or  in  the 
gluteal  region,  but  in  extensive  cases  they  may  open  at  a 
distance  from  the  hip  joint. 

Fig.  27  illustrates  the  type  of  hip  joint  disease  in 
which  the  abscess  formation  resulted  in  numerous 
sinuses.  In  this  case  eight  sinuses  had  existed  for  four 
years,  three  of  these  having  recently  closed.  The  open 
sinuses  show  the  large,  pouting  granulations  which  fol- 
low the  injections  of  the  bismuth  paste. 

Not  infrequently  the  sinuses  open  near  the  anus  or 
scrotum,  and  thus  may  be  mistaken  for  rectal  fistulae.    In 


SINUSKN  FOLLOWING  OTHER  DISEASES. 


87 


one  of  my  cases  the  abscess  had  ruptured  into  the  blad 
der  and  thus  the  existing  sixteen  sinuses  kept  on  dis 
charging  the  urine  for  seven  years.1 

At  times  the  acetabulum  is  perforated  and  the  abscess 


Fig.   27.      Sinus  openings  showing  large  pouting  granulations  after  bismuth  in- 
jections. 


will  rupture  into  the  pelvis,  undermine  the  pelvic  fascia, 
and  open  above  or  below  Poupart's  ligament.  This  com- 
plication, which  increases  the  difficulty  of  treatment,  was 
present  in  5  cases  in  my  series  of  38.  The  radiographs 
after    the   bismuth    injections    have   in    every   instance 


1  Beitrage  zur  Klinische  Chirurgie,  bd.   62.  h.  2.  s.  40. 


88  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

cleared  up  the  diagnosis  as  to  the  origin  and  distribution 
of  these  sinuses. 

We  are  all  familiar  with  the  extreme  chronicity  of  the 
affection.     In  our  series  of  cases, 

15  cases  had  sinuses  from  1  to  3  years. 

9  cases  had  sinuses  from  3  to  10  years. 
10  cases  had  sinuses  from  10  to  15  years. 

5  cases  had  sinuses  from  15  to  20  years. 

1  case  had  sinuses  for  22  years. 

1  case  had  sinuses  for  41  years. 

Most  of  these  patients  contracted  their  hip  disease  in 
early  childhood,  passed  the  acute  stage  of  the  disease, 
and  after  years  of  treatment,  either  operative  or  pallia- 
tive, remained  uncured. 

The  mortality  in  hip  joint  disease  is  probably  lessened 
each  year  because  of  our  improved  methods  and  conserva- 
tive treatment.  Statistics  compiled  some  years  ago  show 
an  appalling  mortality. 

Konig  placed  the  mortality  at  40.3  percent. 

Alexandria  Hospital  (384  cases),  26  percent. 

Gibney  reports  288  cases,  with  a  mortality  of  12.5  per- 
cent. 

The  mortality  is  lower  in  children  than  in  adults. 

A  report  of  100  cases  from  Kocher's  clinic,  by 
Lewiasch,  gives  the  following  mortality: 

In  25  cases  which  had  abscesses,  mortality  of  65  per- 
cent. 

In  75  cases  without  abscesses,  mortality  of  13.3  per- 
cent. 

The  extreme  chronicity  and  the  resistance  to  simple 
treatment  have  forced  the  surgeons  to  adopt  radical  and 
often  desperate  methods.  The  most  extensive  and  dan- 
gerous operations — such  as  excision  of  the  hip  joint,  or 
even  amputations — have  been  performed,  but  past  experi- 
ence has  taught  us  that  even  these  most  radical  proce- 


SINU8ES  FOLLOWING  OTHER  DISEASES.  89 

dures  Lave  in  a  Large  measure  resulted  in  failures.  In  the 
intervals  between  these  operations  the  sinuses  were  irri 
gated  with  various  antiseptic  solutions,  from  the  mildesl 
boric  acid  to  the  corroding  pure  carbolic.  The  favorite 
irrigating  fluid  was  a  weak  solution  of  iodin  or  permanga- 
nate of  potash.  Some  cases  in  our  series  have  given  a 
history  of  many  years'  daily  irrigation  without  any  bene- 
fit. Most  surgeons  have  now  abandoned  the  irrigation  of 
abscess  cavities,  and  substituted  more  modern  and  effect- 
ive methods. 

In  the  light  of  our  present  knowledge  of  the  anatom- 
ical distribution  of  sinuses,  the  injection  of  any  watery 
fluid,  whether  corrosive  or  mild,  no  matter  how  effective 
its  bactericidal  action,  can  be  of  only  temporary  benefit, 
because  the  solution  will  not  reach  all  channels  and 
crevices  of  the  infected  tract,  and,  if  it  does,  it  will  not 
remain  in  contact  with  the  infected  walls  sufficiently  long- 
to  exert  a  therapeutic  action.  The  bismuth  paste  will 
accomplish  this,  and  in  this  principle  I  believe  lies  the 
secret  of  its  effectiveness.  It  possesses  to  a  marked  de- 
gree all  the  above  requisite  qualities.  It  is  liquid  when 
injected,  so  that  it  reaches  all  the  branches  of  the  sinuses, 
and  on  cooling  becomes  semi-solid,  thus  remaining  in  con- 
tact with  every  portion  of  the  infected  tract  long  enough 
to  permit  a  slow  chemical  action. 

Following  are  illustrations  of  the  treatment  of  various 
types  of  hip  joint  disease : 

Example  1.  Hip  Joint  Disease,  Sixteen  Years'  Duration;  Fifteen 
Operations;  Injection  of  Paste;  Cure  in  Thirty  Days. — Miss  M.  G., 
aged  21,  developed  a  painful  condition  of  her  right  knee  and  hip  at 
the  age  of  six.  For  one  year  she  was  treated  symptomatically,  and 
then  a  diagnosis  of  hip  joint  disease  was  made  by  aspirating  pus  from 
the  hip.  Incision  and  drainage  (at  that  time  considered  the  proper 
procedure)  was  made.  Condition  was  thus  aggravated,  and  after 
six  months  of  extreme  suffering,  often  requiring  chloroformization  dur- 
ing dressings,  a  radical  operation  was  performed,  consisting  in  the  re- 


90 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


section,  of  the  head  of  the  femur.  This  radical  procedure,  however, 
resulted  in  the  formation  of  many  sinuses  and  persistence  of  fever. 
During  the  following  ten  years  she  submitted  to  thirteen  more  or  less 


Fig.   28.     Radiograph  showing  sinuses  within  hip  after  sixteen  years'  suppura- 
tion.    Closure  in  one  month ;  no  recurrence. 


radical  operations,  at  intervals  of  from  six  months  to  three  years, 
all  of  which,  however,  were  of  no  avail.  The  discharge  and  pain  per- 
sisted.    The  last  operation  was  performed  by  the  late  Professor  Senn 


K1NUKKS  FOLLOWING  OTHER  DISEASES. 


91 


in  June,  1907.  It  was  the  most  radical  procedure  thus  far  undertaken; 
hoth  trochanters  were  removed  and  the  acetabulum  was  thoroughly 
curetted.  The  five  sinuses,  however,  kept  on  discharging  pus.  In 
December,  1907,  the  first  injection  of  bismuth  paste  was  made,  and 
repeated  every  two  or  three  days,  and  on  January  15  the  sinuses  were 
closed,  and  have  remained  thus  to  date.  The  radiograph  (Fig.  28) 
shows  the  extreme  destruction  of  the  joint,  the  end  of  the  femur,  in- 


Fig.   29.     Radiograph  showing  path  of  sinus  into  hip  joint. 
B,  small  abscess  cavity. 


A,  sinus  opening 


eluding  both  trochanters,  having  been  removed.  The  rim  of  the  ace- 
tabulum is  filled  with  the  bismuth  paste,  showing  distinctly  a  col- 
lateral sinus. 

Example  2.  Hip  Joint  Disease,  Six  Years'  Duration;  One  Sinus; 
Closure  in  Four  Months. — Miss  M.  W.,  aged  13,  was  well  until  her 
seventh  year,  when  she  fell,  striking  her  hip.  No  serious  conse- 
quences   were    discovered    until    two    years    later.     She   was   taken    to 


92 


BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


St.  Joseph's  Hospital  in  Chicago,  where  her  case  was  diagnosed  as 
tuberculosis  of  the  hip;  injected  with  a  10-percent  iodoform-glycerin 
emulsion,  and  the  limb  put  into  a  plaster  of  paris  cast.  Three  months 
later  the  cast  was  removed,  and  from  that  time  the  injections  of  iodo- 
form were  repeated  until  nine  had  been  given.  An  abscess,  neverthe- 
less, formed,  which  ruptured  on  the  external  side  of  her  thigh,  near 
the  middle  of  the  femur.  The  sinus  resulting  therefrom  persisted  in 
discharging  large  quantities  of  green,  malodorous  pus  for  three  years, 
requiring  daily  dressing.  She  was  unable  to  move  about  without  the 
aid  of  crutches,  owing  to  the  tenderness  in  her  hip. 


Fig.   30.     Hip  joint  disease,  nineteen  years'  duration, 
gluteal  region  ;  S,  S,  S,  sinus  openings. 


C,  incision  of  abscess  in 


On  February  28,  1908,  when  she  first  came  for  treatment,  she  was 
very  much  emaciated,  pale,  and  weak,  with  a  shortening  of  four  inches 
of  her  left  limb,  and  a  sinus  on  the  anterior  surface  of  her  left  thigh, 
discharging  pus. 

A  radiograph  taken  demonstrated  the  destruction  of  the  head  of  the 
femur.  A  second  stereoscopic  radiograph  (Fig.  29),  taken  after  the  first 
bismuth  paste  injection,  demonstrated  that  the  sinus  extended  from  the 
opening  on  her  thigh  upward,  in  front  of  the  trochanter,  winding  its 
way  backward  toward  the  acetabulum,  and  there  filling  a  small  cavity 
in  front  of  the  ramus  of  the  ischium. 

The  discharge  diminished  after  the  first  injection,  and  its  character 
changed  to  a  seropurulent  fluid,  resembling  dish-water.     After  twenty 


SINUSES  FOLLOWING  OTHER  DISEASES.  93 

injections  during  a  period  of  four  months  the  sinus  healed,  and  has  re- 
mained so. 

Example  3.  Hip  Joint  Disease,  Nineteen  Years'  Duration;  Required 
Curettage  Before  Injection. —  (Fig  30.)  The  patient  is  2G  years  of  age, 
and  has  had  since  his  sixth  year  a  hip  joint  disease,  which  resulted 
in  the  entire  destruction  of  the  head  of  the  femur,  and  four  sinuses, 
which  latter  continued  to  discharge  for  nineteen  years.  The  radio- 
graphic examinations  proved  that  a  large  sequestrum  was  at  the  bot- 
tom of  the  suppurating  focus  and  that  its  removal  would  be  required 
before  a  cure  could  be  accomplished.  This  was  done  in  May,  1909. 
Two  large  sequestra  were  removed,  and  an  abscess,  undermining  the 
entire  left  gluteal  region,  was  discovered  during  the  operation.  A 
large  counter-incision  (C)  was  made,  and  through  this  the  abscess 
was  traced  into  the  pelvic  cavity.  After  a  few' days'  packing  with 
gauze  the  cavities  were  filled  with  bismuth  paste,  and  within  four 
weeks  all  sinuses  were  closed.  The  temperature,  which  had  con- 
stantly been  high,  became  normal,  and  patient  gained  forty  pounds 
in  weight. 

Sinuses  from  Pyogenic  Osteomyelitis  of  the  Femur. 

The  femur  is  the  most  frequent  seat  of  nontnberculous 
osteomyelitis.  During  the  past  four  years  we  have 
treated  at  the  North  Chicago  Hospital  57  cases  of  non- 
tuberculous  osteomyelitis,  occurring  in  the  following 
parts : 

20  in  the  femur. 

12  in  the  tibia. 

1  in  the  fibula  (syphilitic). 
6  in  the  humerus. 

4  in  the  radius  (3  syphilitic). 
4  in  the  ulna  (3  syphilitic). 

2  in  the  ribs. 

8  in  the  fingers. 

Of  the  20  femur  cases, 

9  occurred  in  the  right  and  11  in  the  left  limb. 

14  were  males  and  6  females. 

15  were  adults  and  5  children. 

The  lower  half  of  the  femur  is  most  frequently  affected, 
the  disease  having  occurred  nineteen  times  below  and 
only  once  above  the  middle.     The  cause  of  this  unequal 


94         BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

distribution  has  not  been  determined,  but  is  likely  due 
to  the  anatomical  difference  in  structure,  the  lower  end 
having  a  much  wider  medullary  canal  than  the  upper 


Fig.  31.     Nontuberculous   osteomyelitis   of  femur.     A,  density  of  bone ;  B,  se- 
questra after  removal. 


portion  of  the  femur,  which  predisposes  the  lower  to  the 
infection. 

Nontuberculous  sinuses  in  this  location  are  usually 
two  in  number — one  external,  in  the  groove  between  the 
biceps  femoris  and  the  vastus  lateralis,  and  the  other  on 


SINUSES  FOLLOWING  OTHER  DISEASES.  95 

the  interna]  side,  in  the  groove  between  the  semi-tendi- 
nosus  and  semi-membranosus.  Of  our  20  cases,  in  only 
one  instance  lias  a  sinus  existed  in  the  popliteal  space.  In 
most  cases  there  exists  a  marked  hypertrophic  sclerosis, 
as  plainly  shown  in  the  radiographs,  where  the  part  af- 
fected is  at  times  nearly  twice  its  normal  thickness,  and 
so  vitrified  that  the  medullary  canal  is  obliterated  and 
the  entire  width  of  the  shaft  gives  a  shadow  of  uniform 
density.  This  hardening  of  the  bone  structure  is  a  re- 
sult of  chronic  inflammation,  and  causes  considerable 
difficulty  during  operations,  it  being  almost  impossible 
in  some  cases  to  cut  the  bone  with  a  sharp  chisel.  At 
times  there  are  foci  of  infection  or  small  sequestra,  en- 
capsulated in  such  a  hard  shell  of  bone,  and  their  re- 
moval thus  becomes  extremely  difficult. 

I  cite  a  typical  case  of  this  variety  for  illustration. 

A.  H.,  aged  29,  was  always  well  until  February,  1907,  when  a  swell- 
ing appeared  above  his  left  knee,  accompanied  by  chills,  fever,  and 
pain.  Physician  lanced  the  swelling  and  removed  a  quart  of  pus. 
Ten  days  later  he  was  operated,  and  four  sequestra  from  the  femur 
were  removed  and  the  wound  drained.  A  sinus  persisted  in  discharg- 
ing profusely  an  irritating  pus. 

In  August,  1908,  he  was  again  operated;  a  radical  curettage  was 
performed,  but  again  without  result. 

In  November,  1908,  I  had  a  radiograph  taken  (Fig.  31),  which  ex- 
plains the  failure.  The  lower  portion  of  the  shaft  is  very  much  thick- 
ened and  the  cancellous  tissue  is  entirely  replaced  by  hard  bone.  An- 
other sequestrum  (A)  is  still  in  the  femur.  The  four  sequestra  (B) 
previously  removed  are  placed  alongside  the  femur  to  show  their  rela- 
tive size  and  shape.  After  the  removal  of  the  last  sequestrum  the 
bismuth  paste  was  injected,  and  rapid  improvement  and  closure  of 
sinus  followed. 

Sinuses  Resulting  from  Tuberculous  Knee  Joint. 

The  same  pathologic  processes  as  described  in  hip  joint 
disease  lead  to  the  sinus  formation  in  knee  joint  tuber- 
culosis. Next  to  the  hip,  it  is  the  most  frequent  seat  of 
this  disease.     Young  individuals  are  most  frequently  the 


96  BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

victims,  one-third  of  all  cases  occurring  before  the  tenth 
year.  Men  are  more  often  affected  than  women. 
Konig's1  series  of  720  cases  treated  shows  60  percent 
were  men. 


Fig.  32.     Bilateral  tuberculosis.    Tibia  in  right  and  femur  in  left  limb  affected. 

In  our  own  series  of  24  cases,  treated  at  the  North 
Chicago  Hospital  during  the  past  four  years,  19  occurred 
in  men  and  only  5  in  women.  Of  these  24,  7  affected  the 
right  and  17  the  left  limb,  just  the  reverse  ratio  to  what 


1  Konig:  Die  Tuberculose  der  Menschlichen  Gelenke. 


WJNIISKS   KOUjOWINU  OTIIKI't  DISKASKS. 


97 


occurs  in  tuberculosis  of  llic  hip,  where  we  encountered 
26  cases  affecting  the  right  side  against  15  the  left. 

Konig  states  that  at  least  one-half  of  the  cases  begin 
with  a  primary  synovial  tuberculosis,  and  from  there 
spread  to  the  adjacent  bones,  while  other  authors  (Tay- 


Figs.  33,  34. 
in  Pig.  32.) 


Fig.  33.  Fig.  34. 

Radiographs  demonstrating  bilateral  tuberculosis. 


(Case  shown 


lor)  assert  that  more  frequently  the  disease  starts  in  the 
bones  and  affects  the  joints  secondarily. 

Any  of  the  four  bones  which  make  up  the  knee  joint 
may  be  the  primary  seat  of  the  disease.  The  lower  end 
of  the  femur  leads  in  frequency  and  is  closely  followed 


98         BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

by  the  upper  end  of  the  tibia.  Primary  tuberculosis  in 
the  patella  is  not  as  rare  as  is  generally  believed;  only 
two  cases,  however,  occurred  in  our  series.  In  Konig's 
720  cases  it  occurred  50  times,  in  33  of  which  the  patella 
was  the  only  bone  involved.  The  fibula  is  rarely  af- 
fected; not  a  single  case  has  occurred  in  our  series. 


Fig.   35.      Demonstration  of  method  of  injection  of  bismuth  paste  into  sinus  of 
the  knee. 


In  one  case  the  disease  was  bilateral.  This  case  has 
so  many  interesting  features  that  I  desire  to  cite  it: 

Example  1.  Bilateral  Knee  Joint  Tuberculosis. — A  boy,  aged  13,  de- 
veloped bilateral  tuberculosis  (Fig.  32)  at  the  age  of  10.  In  both  limbs 
the  disease  progressed  until  sinuses  formed,  which  persisted  in  dis- 
charging purulent  material,  and  also  small  spicula  of  bone.  In  the  right 
limb  only  the  tibia  is  affected,  as  shown  by  the  large  swelling  below  the 


SINUSES  FOLLOWING  OTHER  DISEASES.  99 

knee  and  the  extreme  atrophy  above  the  knee.  In  the  left  limb  the 
femur  is  diseased,  the  swelling  being  above  and  a  contracting  atrophy 
below  the  knee.  The  radiographs  (Figs.  33,  34)  demonstrate  this  con- 
dition most  lucidly.  It  is  remarkable  that,  in  spite  of  this  extensive 
destruction,  neither  the  right  nor  the  left  joint  is  involved.  The  boy  has 
no  pain,  can  stand  erect,  walk  fairly  straight,  and,  moreover,  he  can 
bend  both  knees,  as  shown  in  Fig.  35,  in  which  I  demonstrate  at  the 
same  time  the  method  of  injection  of  these  sinuses  with  bismuth  paste. 
I  have  carried  out  this  treatment  in  this  case  for  the  past  eight 


Fig.  36.     Tuberculous  knee  joint  with  forty-two  sinuses,   sixteen  years'   duration. 

months,  injections  having  been  given  at  ten  days'  intervals,  but  the 
sinuses  continue  discharging.  A  radical  operation — namely,  a  complete 
exenteration  of  the  end  of  the  femur  and  tibia — is  the  indication  under 
those  circumstances,  but  the  knee  joints  should  not  be  opened. 

For  illustration  as  to  what  extent  the  soft  structures 
may  be  undermined  as  a  result  of  tuberculosis  of  the 
knee  joint,  I  cite  another  case: 


100       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

Example  2.     Knee   Joint  Tuberculosis,   with    Forty-two   Sinuses. — In 

this  the  disease  started  when  the  patient  was  6  years  old,  and  sinuses 
began  to  form  until  the  entire  area  from  the  middle  of  the  thigh  down 
to  the  middle  of  the  leg  was  studded  with  profusely  discharging  sinuses 


Fig.   37.     Network  of  sinuses  of  femur.      (Case  shown  in  Fig.  36.) 


(forty-two  in  number,  Fig.  36).  Multiple  openings  make  it  difficult  of 
injection,  as  the  paste  escapes  from  the  nearest  counter-opening,  thus 
failing  to  reach  all  portions  of  the  network  underneath.  The  patient's 
father,  a  physician,  tried  the  bismuth  paste,  and,  while  it  reduced  the 


SINUSKS  FOLLOWING  OTIILK  DISKASKS. 


101 


amount  of  discharge,  it  failed  to  produce  the  closure  of  the  sinuses. 
He  believed  that  this  was  duo  to  faulty  technic,  and  brought  his  son  to 
me  for  treatment. 

While  the  case  seemed  hopeless,  on  account  of  the  extent  of  the 
disease  and  the  failures  in  the  previous  surgical  treatment,  we  never- 
theless decided  to  give  it  a  trial.  A  stereoscopic  radiograph  of  the  knee 
joint  was  made,  and  demonstrates  the  causes  of  failure  by  showing  a 


Fig.   38.      Hopeless  condition  of  old  tuberculous  knee  joint, 
putation  required. 


Eight  sinuses.     Ana- 


large  sequestrum  in  the  tibia.  This  sequestrum  was  removed,  and  then 
all  the  sinuses  were  injected  and  another  radiograph  was  taken.  This 
picture  (Fig.  37)  demonstrates  the  complex  arrangement  of  channels. 

After  this  operation  a  rapid  improvement  followed,  and  the  sinuses 
above  the  knee  also  began  to  close,  indicating  that  the  focus  of  the  dis- 
ease in  the  tibia  was  the  fountain  of  the  constant  discharge.  The  case 
is  still  under  treatment  and  the  final  outcome  yet  undecided. 


102       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

It  is  needless  to  say  that  there  are  some  cases  which 
will  not  yield  to  the  bismuth  paste  treatment.  In  our  own 
series  we  found  that  6  percent  could  not  benefited  after  a 
persistent  treatment  of  at  least  one  year's  duration.  In 
no  case  do  we  give  up  hope  of  an  ultimate  cure  until  after 
at  least  one  year's  treatment. 

Occasionally  we  encounter  a  case  in  which  treatment 
is  not  even  worth  trying.  The  following  case  is  an  ex- 
ample : 

M.  F.,  aged  26,  developed  at  the  age  of  10  a  tuberculous  knee.  In 
spite  of  the  most  skillful  treatment,  the  joint  had  undergone  abscess 
formation,  leaving  it  ankylosed,  with  eight  suppurating  sinuses,  for 
sixteen  years.  The  entire  limb  had  undergone  extreme  atrophy  and  a 
shortening  of  six  and  one-half  inches,  so  that,  even  if  there  had  been 
no  sinuses,  the  limb  would  have  remained  useless. 

A  radiograph,  taken  after  an  injection  of  the  paste  for  diagnostic 
purposes  (Fig.  38),  discloses  the  hopelessness  of  a  cure.  I  therefore 
amputated  above  the  knee  and  had  it  replaced  with  a  useful  artificial 
limb.  The  discarding  of  crutches,  a  gain  in  general  health,  and  a 
great  improvement  in  appearance  were  the  benefits  derived  from  this 
procedure. 

Sinuses  from  Bone  and  Joint  Disease  of  the  Foot. 

The  architecture  of  the  foot  is  such  that  tuberculous 
disease  rarely  affects  a  solitary  bone  or  joint.  The  os 
calcis  is  occasionally  a  solitary  focus.  The  ankle  joint  is 
most  frequently  involved.  In  Fig.  39  we  illustrate  the 
typical  shape  of  an  advanced  tuberculosis  of  the  ankle. 
This  case  is  of  many  years'  duration,  and  was  considered 
hopeless,  an  amputation  having  been  advised  by  several 
surgeons  after  the  radical  operations  had  been  of  no 
avail.  In  1908  the  six  sinuses  were  injected  with  bis- 
muth paste  and  the  treatment  kept  up  for  one  year,  and 
during  this  period  the  foot  was  reduced  in  size,  three 
sinuses  closed,  and  the  three  remaining  have  discharged 
only  a  few  drops  of  serous  fluid.  He  can  walk  without 
crutches,  and  returned  to  his  work,  which  he  had  aban- 
doned since  the  beginning  of  his  disease. 


SINUSES  FOLLOWING  OTHEK  DISEASES. 


103 


Even  the  most  extensive  destruction  in  the  ankle  joint 
may  ultimately  heal,  and  the  limb  may  become  strong 
enough  to  carry  the  body  weight.  The  radiograph  (Fig. 
40)  illustrates  such  a  case. 

Tuberculous  Ankle,  Ten  Years'  Duration. — A  young  man,  aged  19, 
developed  at  the  age  of  9  a  typical  tuberculosis  of  the  ankle,  in  which 


Fig.  39.     Typical  tuberculous  ankle  joint  with  sinuses. 


the  entire  set  of  bones  composing  the  ankle  took  part.  The  destruction 
of  the  joint  was  complete,  abscess  ruptured,  and  sinuses  persisted  for 
ten  years,  but  the  discharge  became  less  profuse  every  year  and  the 
joint  became  small  and  painless. 

In  April,  1909,  I  injected  the  sinuses  three  times,  and  within  a 
month  they  closed  and  remained  so.  The  patient  can  support  his  body 
weight  on  the  healed  limb. 

The  radiograph   (Fig.  40)  has  many  instructive  features.     It  shows 


104       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

that  after  this  extreme  destruction  of  the  joint  nature  has  soldered 
the  rough  bony  ends  together,  and  produced  a  solid  support.  Callous 
deposits  fill  in  all  the  gaps  of  missing  bone. 

Another  pathological  feature  is  here  lucidly  illustrated. 
It  has  been  observed  that  the  bones  in  the  vicinity  of 
tuberculous  disease  are  frequently  deficient  in  lime  salts, 


Fig.   40.      Destruction  of  ankle  joint,  with  ankylosis   (closed).     A,  callus;  B,  B, 
absorption  of  calcium  salts. 


and  therefore  give  a  much  lighter  shadow  than  normal 
bone.  We  note  that  in  this  case  the  os  calcis,  all  the 
tarsal  bones,  and  the  ends  of  the  metatarsals  show  this 
characteristic  deficiency  of  lime  salts,  while  the  tibia 
and  fibula  and  the  distal  parts  of  the  metatarsals  are  per- 
fectly normal,  and  give  a  contrasted  darker  shadow. 


SINUSES  FOLLOWING  OTHER  DISEASES.  105 

Tuberculosis  in  the  os  calcis  is  not  very   rare.    We 

illustrate  a  typical  case  in  Fig.  41: 

A  young  man  of  20  developed  a  painful  swelling  of  his  right  heel  in 
1907.  After  two  months  an  abscess  was  lanced,  but,  instead  of  the 
expected  healing,  a  sinus  remained.  A  radiograph  disclosed  a  seques- 
trum of  a  round  shape,  lodged  in  a  well-formed  cavity  in  the  os  calcis. 
Sequestrum  was  removed  and  a  drainage  on  both  sides  of  the  heel 
established.  The  sinuses  persisted  and  the  disease  extended  upward, 
involving  the  sheath  of  the  tendo  Achillis,  with  formation  of  two  more 
sinuses.     In  this   condition   he   came  to  me  for  treatment.     The   first 


Fig.  41.     Tuberculosis  of  os  calcis  injected  with  bismuth  paste. 

injection  was  made  in  March,  1909,  and  after  three  weeks'  treatment 
the  sinuses  closed  and  remained  so  until  January,  1910,  when  one  of 
them  reopened  and  a  small  amount  of  discharge  returned.  A  few 
additional  injections  of  the  bismuth  paste  closed  the  last  discharging 
sinus. 

Sinuses  from  Tuberculosis  of  the  Elbow  Joint. 

This  disease  shares  the  general  characteristics  of  tuber- 
culous infection  in  other  joints.  It  occurs,  however, 
more  frequently  in  young  girls  than  in  boys;  affects  the 


106       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

right  arm  at  least  10  percent  more  often  than  the  left. 
All  three  bones  comprising  the  joint  may  be  affected,  bnt 
the  humerus  most  frequently.  Of  128  cases  cited  by 
Konig  the  radius  was  only  twice  affected,  while  the  olec- 
ranon process  was  affected  in  36  cases.  The  disease  is 
primary  in  the  bones  in  about  70  percent  of  cases,  and  in- 
vades the  joint  secondarily.  If  not  arrested  in  its  initial 
stages,  it  will  progress  as  usual  to  abscess  formation  and 
rupture,  with  the  ultimate  sinus  formation.  In  Konig 's 
128  cases  35  percent  had  abscesses,  and  in  53  percent 
sinuses  were  present.  It  must  be  remembered  that  his 
statistics  comprise  material  of  several  decades,  and 
therefore  do  not  represent  the  proportion  of  sinuses  of 
recent  years.  With  the  modern  and  conservative  treat- 
ment introduced  in  the  last  few  years,  the  formation  of 
sinus  has  been  reduced  to  a  great  extent,  and,  as  will  be 
shown  in  the  chapter  on  the  Conservative  Treatment  of 
Cold  Abscesses,  the  sinus  formation  can  be  prevented  in 
practically  all  cases.  When,  however,  the  sinuses  al- 
ready exist,  the  bismuth  treatment  is  indicated,  no 
special  technic  being  required  for  this  class  of  cases. 

The  wrist  so  resembles  the  ankle  joint  in  architecture 
that  the  disease  affects  both  in  similar  manner.  The 
number  of  small  bones  and  joint  surfaces  predispose  to 
a  rapid  extension  of  the  tuberculosis,  and  therefore  it  is 
rarely  confined  to  one.  In  the  wrist  more  than  else- 
where the  disease  leads  to  abscess  and  sinuses,  but  these 
sinuses  respond  promptly  to  the  bismuth  paste  treatment. 
Of  10  cases  in  our  series,  only  2  required  curettage;  the 
remainder  healed  after  one  or  more  injections  without 
surgical  interference. 

The  smaller  bones  and  joints  of  the  hand  and  foot  are 
subject  to  the  same  infections,  pyogenic  or  tuberculous, 
and  the  resulting  sinuses  yield  to  the  same  treatment  as 
those  of  other  joints. 


SINUSES  FOLLOWING  OTHEK  DISEASES. 


107 


Sinuses  from  Tuberculous  Ribs  and  Sternum. 

Tuberculous  abscesses  on  the  thorax  wall  rarely  origi- 
nate in  the  soft  structures.  Almost  without  exception 
they  are  the  result  of  a  bone  tuberculosis.  Leaving1  out 
sinuses  resulting  from  empyema  and  those  from  spon- 


Fig.   42.      Sinuses  supposed  to   have   originated   from   ribs,   found   to   be  due   to 
tuberculosis  of  sternum. 


dylitis,  we  may  regard  every  sinus  of  the  chest  wall  as 
that  of  a  rib  or  sternum. 

The  ribs  furnish  about  five  times  as  many  cases  as  the 
sternum,  and  most  of  them  are  of  tuberculous  origin, 
only  a  small  fraction  originating  from  typhoid  or  pyo- 
genic infection.  Men  are  more  frequently  affected  than 
women,  usually  between  20  and  40  years  of  age.     The 


108       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

tuberculous  foci  are  rarely  larger  than  a  cherry,  usually 
affecting  less  than  one  inch  of  the  rib.  Their  most  favor- 
ite location  is  in  the  anterior  curve  of  the  third  to  the 
ninth  rib.     Tuberculosis  of  the  ribs  runs  a  very  chronic 


Fig.  43.  Patient  of  radiograph  shown  in  Fig.  42.  A,  incision  of  first  opera- 
tion ;  B,  incision  of  second  operation  ;  C,  incision  for  removal  of  sequestrum  in 
sternum.     Closure  ef  all  sinuses  after  removal  of  sternal  focus. 

course,  often  requiring  months  before  an  abscess  forms, 
and  the  sinuses  may  open  at  quite  a  distance  from  the 
diseased  focus.  At  times  the  disease  originates  in  the 
sternum,  and  the  abscess  undermines  the  chest  muscles 


SINUSES  FOLLOWING  OTHER  DISEASES.  J  09 

and  opens  clear  over  at  the  side  of  the  chest  wall,  produc- 
ing a  sinus  opening  so  far  from  the  original  focus  as  to 
mislead  one  in  the  diagnosis.  The  following  case  will 
illustrate  this: 

Tuberculosis  of  the  Sternum  Mistaken  for  Tuberculosis  of  Ribs. — 
T.  L.,  aged  21,  developed  when  1G  multiple  abscesses  on  the  left  side 
of  his  chest,  below  the  nipple  line.  The  same  were  drained,  but,  in- 
stead of  spontaneous  closure,  they  persisted  discharging  for  a  year. 
The  diagnosis  of  tuberculosis  of  the  rib  was  made  and  a  part  of  the 
ninth  rib  was  resected.  This  did  not  alter  the  condition,  and  a  year 
later  another  radical  operation  was  performed;  the  entire  undermined 
area  was  curetted  and  a  section  of  the  fifth  rib  resected.  Five  sinuses 
remained  after  this  operation,  and  persisted  in  discharging  a  purulent, 
very  irritating  pus  for  another  three  years. 

With  this  history  he  came  to  me  in  the  spring  of  1909.  My  sus- 
picion that  this  was  a  tuberculosis  of  the  sternum  and  not  of  the  ribs 
was  verified  by  the  radiograph  (Fig.  42),  in  which  it  is  shown  that  the 
sinuses  led  toward  the  sternum.  Without  opening  any  of  the  old 
sinuses,  some  of  which  were  in  the  axillary  line,  I  made  an  incision 
near  the  sternum,  where  I  found  some  of  the  paste  injected  the  day 
before.  Following  the  tract  of  the  paste  toward  the  median  line,  I 
found  a  sequestrum  the  size  of  a  silver  quarter.  This  was  removed 
and  the  cavity  packed  with  gauze,  followed  by  three  injections  of  paste 
(33  percent).  Subsequent  to  this  operation,  and  without  any  surgical 
treatment  to  the  other  sinuses,  the  entire  set  of  them  closed  within  a 
month,  as  shown  in  Fig.  43,  and  remain  so  to  date. 


CHAPTER  VIII. 

POST-OPERATIVE  SINUSES  FOLLOWING  ABDOMI- 
NAL AND  KIDNEY  OPERATIONS. 

A  decade  ago,  when  it  was  customary  to  drain  the 
abdomen  after  nearly  all  laparotomies  for  suppurative 
conditions,  post-operative  fistulas  were  relatively  fre- 
quent, especially  when  silk  had  been  used  for  tying  pedi- 
cles. At  the  present  time  of  aseptic  surgery,  with  our 
knowledge  of  the  harmlessness  of  sterile  pus  and  the 
acquired  local  immunity  in  chronic  abscesses,  we  have 
been  taught  not  to  drain  as  frequently,  and  therefore 
post-operative  fistulae  are  rather  uncommon.  Neverthe- 
less, there  still  exist  quite  a  number  of  cases,  carried  over 
from  the  drainage  period,  some  of  which  have  lasted  for 
many  years. 

Another  variety  of  abdominal  fistulae  are  those  result- 
ing from  the  worst  forms  of  tuberculous  peritonitis,  or 
rupture  of  subphrenic  or  appendiceal  abscesses. 

In  these  varieties  of  sinuses  I  have  tested  the  efficacy 
of  the  bismuth  paste  treatment,  and,  while  the  number 
of  cases  is  small,  certain  lessons  can  be  drawn  from  my 
observations  which  may  aid  in  the  future  treatment  of 
this  class  of  cases.  Our  experience  is  limited  to  thirteen 
abdominal  cases,  four  of  which  were  the  results  of  tuber- 
culous peritonitis  and  nine  cases  of  post-operative  sinuses 
after  laparotomies. 

Sinuses  Following  Tuberculous  Peritonitis. 

Two  of  the  four  cases  in  which  tuberculous  peritonitis 
was  the  cause  of  the  sinuses  were  not  in  the  least  bene- 

110 


SINUSES  FOLLOWING  CERTAIN  OPERATIONS.         1  1  1 

fited  by  the  bismuth  treatment,  gradually  wasted,  and 
died.  Both  cases  belonged  to  the  most  malignant  type, 
and  each  had  a  fecal  fistula  besides  the  suppurating 
sinuses. 

The  first  case,  shown  in  Fig.  44  (a  young  man  aged  23),  took  from 
the  beginning  a  most  violent  course,  simulating  acute  suppurative  ap- 
pendicitis, but  a  positive  ophthalmo  reaction  and  other  symptoms  con- 
vinced us  that  we  had  to  deal  with  tul  ^rculous  peritonitis.  Within 
six    months    the    patient   was    emaciated   to   a    skeleton,    and    a    sinus 


Fig.  44.     Sinus  and  fecal  fistula  in  tuberculous  peritonitis. 


formed  just  below  the  umbilicus,  in  the  line  of  incision,  and  soon 
thereafter  a  fecal  fistula  complicated  this  condition.  A  violent  eczema 
aggravated  the  already  unbearable  condition,  and  thus  he  succumbed 
to  the  disease.  Six  injections  had  been  made  into  the  sinuses  without 
any  effect. 

The  second  case  was  that  of  a  young  man  who  was  referred  to  us 
by  his  physician  after  the  abdominal  sinuses  and  fecal  fistula?  had 
already  existed  for  several  weeks.  Following  the  first  few  bismuth 
injections  he  seemed  to  improve  and  began  to  walk,  but  soon  after 
relapsed  and  gradually  wasted  away  and  died.  A  post-mortem  was 
obtained.     It  proved  to  us  the  futility  of  this  or  any  other  treatment 


112       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

in  cases  which  have  reached  this  stage.  The  disease  had  invaded  the 
entire  abdominal  cavity  to  such  an  extent  as  to  convert  the  intestines 
into  a  firm  mass,  in  which  were  locked  up  hundreds  of  abscesses. 
The  paste  was  seen  to  have  reached  only  one  of  these  abscess  sacs. 
The  duodenum  showed  a  perforated  ulcer.  The  cecum  was  evidently 
the  primary  focus  of  the  disease,  it  having  been  transformed  to  a  mass 
of  tuberculous  tissue. 

With  the  experience  in  these  two  cases,  I  do  not  advise 
the  use  of  the  paste  in  tuberculous  peritonitis  when  it  has 
reached  this  malignant  and  hopeless  stage. 

Whether  the  paste  will  be  of  value  in  the  earlier 
stages  or  the  less  malignant  forms  of  tuberculous  perito- 
nitis is  still  a  problem.  There  has  always  been  some- 
thing mysterious  about  the  spontaneous  cures  of  tuber- 
culous peritonitis;  nearly  every  remedy  tried  has  been 
successful,  and  finally  it  was  found  that  the  simple  open- 
ing of  the  abdominal  cavity  was  all  that  was  necessary  to 
produce  a  cure.  It  has,  however,  been  found  that  many 
of  these  mysterious  cures  were  only  apparent,  and  that 
recurrences  took  place.     (Mayo.1) 

In  St.  Mary's  Hospital  at  Rochester,  Minnesota,  where 
in  a  period  of  ten  years  (1894-1904)  89  cases  of  tubercu- 
lous peritonitis  were  operated  upon  by  simply  removing 
the  fluid,  most  of  them  improved.  It  was  noted,  how- 
ever, that  a  considerable  percentage  returned  for  further 
treatment,  and  thus  it  was  shown  that  the  improvement 
had  been  only  temporary.  Some  were  reoperated  as 
many  as  four  or  five  times  without  any  permanent  result. 
In  1902  Dr.  J.  B.  Murphy  called  attention  to  the  fact  that 
when  tuberculous  peritonitis  was  present  the  mucosa  of 
the  fimbriated  end  of  the  Fallopian  tube  on  one  or  both 
sides  would  usually  be  found  everted  and  the  tube  con- 
siderably thickened.  This  fact  was  readily  verified  dur- 
ing the  subsequent  operations,  and  the  majority  of  female 


iMayo:  Surgical  Tuberculosis  in  the  Abdominal  Cavity. — Journal  American 
Medical  Association,  April  15,  1905. 


SINUSES  FOLLOWING  CERTAIN  OPERATIONS.         113 

patients  with  tuberculous  peritonitis  showed  a  thicken- 
ing of  the  tubes.  On  removal  of  these  tubes,  typical 
tubercular  ulcers  of  the  mucous  membrane,  with  cheesy 
deposits,  were  discovered,  and  in  many  instances  the 
tubercle  bacilli  could  be  stained.  In  the  minority  of  cases 
the  tubes  were  normal. 

This  knowledge  was  at  once  taken  advantage  of,  and 
in  the  subsequent  laparotomies  for  tuberculous  peri- 
tonitis the  disease  focus  was  radically  removed  whenever 
it  could  be  located.  Of  26  tubal  resections  for  tubercu- 
lous peritonitis  performed  by  Drs.  Mayo,  25  recovered. 
Of  these,  7  had  been  previously  operated  from  one  to 
four  times.  In  not  one  single  patient  has  a  secondary 
operation  been  necessary  thereafter. 

This  striking  example  from  such  a  reliable  source 
teaches  us  the  lesson  that  tuberculous  peritonitis  is  prac- 
tically always  secondary,  and  that  by  removing  the 
primary  focus  the  peritoneum  will  usually  take  care  of 
itself  and  a  permanent  cure  will  be  obtained.  In  other 
words,  if  the  source  of  the  constant  reinfection  could  be 
eradicated,  the  peritoneum  would  undergo  spontaneous 
healing. 

The  primary  sources  of  tuberculous  peritonitis  are  the 
Fallopian  tubes,  the  appendix,  the  mesenteric  glands, 
and  ulcerations  of  the  intestines.  Since  we  know  that 
this  peritonitis  is  practically  always  secondary  to  tuber- 
culous disease  of  other  organs  in  the  abdomen,  it  would 
be  irrational  to  treat  the  peritonitis  and  ignore  its 
source.  Surgical  treatment  is  the  proper  procedure,  and. 
as  shown  by  Mayo,  the  removal  of  the  primary  focus 
gives  a  splendid  chance  for  permanent  cure. 

This  remarkable  fact  has  its  analogy  in  other  tubercu- 
lous conditions.  For  instance,  in  tuberculosis  of  the  kid- 
ney there  is  frequently  a  coexisting  tuberculosis  of  the 


114       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

bladder.  As  soon  as  the  kidney  is  removed,  the  bladder 
will  usually  heal  spontaneously.  Again,  the  removal  of 
a  tuberculous  tonsil  will  frequently  cure  an  infected 
chain  of  lymph  glands.  A  similar,  but  not  so  well-estab- 
lished, example  of  this  principle  is  that  observed  by 
Brauer,  Forlanini,  Murphy,  and  others — that  when  one 
tuberculous  lung  is  collapsed  (nitrous  oxide  gas  injec- 
tions into  the  pleural  space),  and  healing  has  taken 
place,  a  coexisting  focus  in  the  other  lung,  when  present, 
will  also  be  favorably  affected. 

The  regularity  with  which  this  spontaneous  healing 
occurs  precludes  the  possibility  of  coincidence,  and  re- 
quires an  explanation.  Is  it  not  possible  that,  through  the 
removal  of  a  large  portion  of  the  diseased  tissue,  our  body, 
which  has  acquired  such  high  degree  of  immunity  during 
the  gradual  development  of  the  disease,  is  suddenly  relieved 
of  the  source  of  a  large  quantity  of  toxins,  and  the  existing 
high  degree  of  immunity  is  powerful  enough  to  cope  with  the 
balance  of  microorganisms  still  operating  in  other  parts  of 
the  body?  In  other  ivords,  is  it  not  likely  that  during  the 
development  of  the  disease  the  degree  of  immunity  keeps 
pace  with  the  progress  of  the  disease,  and  that  the  sudden 
removal  of  a  part  of  the  diseased  tissue  leaves  the  system  a 
sufficient  degree  of  immunity  to  combat  the  remaining  quan- 
tity of  disease  in  the  body?  I  have  undertaken  a  series  of 
experiments  on  lower  animals,  such  as  swine  and  guinea 
pigs,  to  prove  this  theory,  but  it  is  too  early  to  permit  of 
the  publication  of  the  results. 

Surgical  treatment,  therefore,  is  the  most  rational  in 
tuberculous  peritonitis,  and  only  when  the  removal  of 
the  original  focus  of  the  disease  has  failed  to  check  the 
progress  are  other  methods,  such  as  injection  of  various 
oils  and  emulsions,  to  be  employed. 

I  desire  to  warn  the  practitioner  against  injecting  large 


SINUSES  FOLLOWING  CERTAIN  OPERATIONS.         115 

quantities  of  the  bismuth  paste  into  the  peritoneal  cavity, 
because  the  extensive  surface  for  absorption  may  lead  to 
bismuth  poisoning.  It  may  be  permissible  to  injecl  a 
few  drams  of  a  10-percent  bismuth  paste  in  the  earlier 
stages,  where  the  focus  of  the  disease  has  already  been 
removed.  We  have  tried  this  in  two  cases,  and,  although 
we  have  obtained  splendid  results  in  both,  I  do  not  yet 
consider  this  a  sufficient  test  for  its  advocacy. 
A  brief  history  of  these  cases  may  be  of  service: 

Case  1.  Tuberculous  Peritonitis;  Bismuth  Treatment;  Cure. — Miss 
L.  M.,  aged  23,  developed  in  1907  symptoms  of  chronic  appendicitis. 
An  operation  revealed  a  tuberculous  peritonitis  without  adhesions,  but 
the  intestines  and  omentum  were  studded  with  tubercles.  At  the  base 
of  this  was  found  a  tuberculous  appendix,  which  was  removed. 

Instead  of  gaining,  she  continued  to  lose  in  weight  and  strength, 
and  was  sent  to  California,  where  she  remained  for  six  months.  Not 
improving,  the  physicians  there  advised  her  to  return,  pronouncing 
her  case  hopeless.  Upon  her  return  to  Chicago,  in  1909,  I  proposed  to 
try  the  injection  of  a  small  quantity  of  paste  into  the  peritoneal  cav- 
ity. The  parents  consented  and  the  procedure  was  as  follows:  through 
a  small  incision  in  the  abdominal  wall  above  the  left  inguinal  ring 
three  drams  of  a  10-percent  paste  were  injected  and  the  incision  closed 
in  the  usual  way.  With  the  purpose  of  spreading  the  paste  over  the 
surface  of  the  intestines,  a  gentle  massage  of  the  abdomen  was  made. 
For  three  weeks  following  this  procedure  she  was  rather  ill,  running 
a  temperature  of  100°  every  day,  and  apparently  losing  ground,  but 
after  that  period  she  began  to  improve  in  every  way,  so  that  after  one 
year  she  regained  her  health  and  is  able  to  attend  general  household 
duties.     Locally,  there  are  no  symptoms  of  peritonitis. 

Case  2.  Sinus  Following  Tuberculous  Peritonitis;  Bismuth  Treat- 
ment; Cure. — Mrs.  K.  H.  was  treated  in  1908  for  tuberculosis  of  the 
glands  of  the  neck.  An  extensive  and  radical  operation  was  followed 
by  a  tedious  process  of  suppuration,  and  deep-seated  sinuses  persisted 
until  they  healed  with  bismuth  injections.  Thereafter  patient  spent  a 
year  of  perfect  health  in  Colorado.  Upon  her  return  to  Chicago  she 
developed  a  large  abdominal  exudate  and  lost  considerably  in  weight; 
ophthalmo  reaction  was  positive.  Exploratory  laparotomy  was  per- 
formed by  Dr.  Carl  Beck  (my  brother).  The  abdomen  was  studded 
with  thousands  of  tubercles,  and  both  Fallopian  tubes  were  thick  and 
tuberculous.  He  removed  both  tubes  and  closed  the  abdomen;  pri- 
mary union  took  place.  Six  weeks  later  the  scar  reopened  and  dis- 
charged a  quantity  of  cheesy  material  and  pus.  The  sinuses  showed 
no  tendency  to  closure,  and  the  bismuth  injections  were  then  instituted. 


116       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

In  the  radiograph  (Fig.  45)  we  can  plainly  trace  the  path  of  the  sinus 
to  the  original  focus  in  the  region  of  the  tubes.  After  one  month's 
treatment  with  paste  injections  the  sinus  closed,  and  patient  is  now  in 
good  health. 

Although  the  final  result  in  these  last  two  cases  is  very 
satisfactory,  I  advise  the  most  extreme  conservatism  in 


Pig.  45.     Sinus  following  tuberculous  peritonitis  after  removal  of  the  adnexa. 

the  use  of  the  paste  in  this  class  of  cases,  and  would  limit 
its  use  to  those  cases  in  which  a  fistula  remains  after  a 
radical  operation,  barring  the  hopeless  cases,  such  as  I 
have  cited  in  the  beginning  of  this  chapter. 


SINUSES  FOLLOWING  CERTAIN  OPERATIONS.         117 

Post-Operative  Abdominal  Fistula  of  Pyogenic  Origin. 

Nine  cases  of  this  variety  were  treated  with  bismuth 
paste.  This  series  does  not  include  post-operative  fecal 
fistulae,  which  are  considered  separately  in  another  chap- 
ter. The  sinuses  in  the  above  nine  cases  were  of  from 
two  months'  to  three  years'  duration,  all  resulting  from 
drainage  following  abdominal  operations.  In  eight  of 
these  nine  cases  the  treatment  was  effective,  requiring 
from  one  to  thirty  injections  for  their  closure;  in  the  re- 
maining case  the  bismuth  treatment  produced  no  effect. 

The  usual  technic  was  applied  in  their  treatment.  I 
shall  cite  the  case  in  which  the  treatment  failed,  because 
we  can  learn  more  from  the  failures  than  from  the  suc- 
cessful cases. 

Case  9.  This  case,  in  which  the  bismuth  treatment  also  failed,  was 
a  sinus  occurring  after  a  laparotomy  performed  two  years  ago.  The 
radiograph  shows  a  large  cavity  in  the  pelvis,  and  a  tumor  is  present, 
which  appears  to  be  a  pyosalpinx  filling  the  left  side  of  the  pelvis. 
The  abscess  cavity  evidently  originates  from  a  diseased  tube,  and  thus 
we  can  not  expect  a  closure  of  the  sinus  until  the  diseased  mass  is 
eradicated. 

The  remaining  eight  cases  responded  promptly  to  the  treatment, 
especially  those  which  were  of  long  duration.  I  am  certain  that  many 
physicians  have  had  cases  similar  to  those  just  cited,  and  their  ex- 
periences will  probably  tally  with  those  of  mine. 

I  do  not  advise  the  use  of  the  paste  in  recently  operated 
cases  in  which  a  spontaneous  healing  may  be  expected  in 
due  time.  Only  in  those  cases  where  the  healing  is  very 
much  protracted,  and  where  there  is  no  tendency  to  spon- 
taneous closure,  are  we  justified  in  using  the  paste. 

It  must  be  remembered  that  the  newly-formed  ad- 
hesions of  drainage  channels  are  very  thin  and  may  tear 
at  even  moderate  overdistention  with  the  paste,  and  thus 
open  fresh  areas  for  infection.  Moreover,  we  must  bear 
in  mind  that  fresh  surfaces  absorb  the  metallic  bismuth 
much  quicker  than  the  hard  fibrous  walls  of  chronic 


118       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

sinuses,  and  thus  the  excessive  absorption  may  lead  to 
bismuth  intoxication.  Again,  I  warn  against  the  use  of 
the  paste  when  the  abdominal  wound  is  in  a  state  of  acute 
inflammation;  here  it  may  even  aggravate  the  condition. 

Sinuses  from  Tuberculous  Kidneys. 

Not  all  sinuses  in  the  loin  originate  from  the  kidney. 
They  may  be  the  result  of  spondylitis  or  sacral  tubercu- 
losis. The  latter  two  have  already  been  discussed  in  the 
respective  chapters,  and  their  mention  here  is  necessary 
only  to  point  out  that  every  sinus  in  the  region  of  the 
kidney  is  not  necessarily  a  kidney  sinus.  The  history  of 
the  case  and  the  entirely  different  symptoms  in  these  two 
affections  leave  very  little  chance  for  diagnostic  error; 
nevertheless,  under  unfavorable  conditions  a  sinus  from 
tuberculous  disease  of  the  kidney  may  be  mistaken  for 
one  of  spinal  origin.     I  cite  such  a  case  on  page  122. 

When  these  sinuses  lead  from  the  bed  of  the  kidney, 
they  may  have  their  origin  in  either  the  kidney  substance 
or  result  from  a  perinephritic  abscess — one  which  either 
ruptured  spontaneously  or  had  been  incised  and  drained. 
Another  variety  is  the  post-operative  sinus  resulting 
from  nephrotomy  or  nephrectomy. 

The  results  obtained  in  this  form  of  sinuses  by  means 
of  the  bismuth  paste  treatment  have  been  most  gratify- 
ing, because  the  prospects  for  a  cure  seemed  scant  and 
the  results  were  surprisingly  good.  The  most  recent  re- 
port on  the  therapeutic  effects  of  bismuth  paste  on  sinuses 
following  nephrectomies  is  that  of  Heitz,  Boyer,  and 
Morens.  They  treated  11  most  refractory  cases  in  a  Paris 
hospital,  with  the  result  of  8  complete  and  1  relative 
cures,  the  two  remaining  cases  being  improved  and  still 
under  treatment.  The  cases  are  reported  in  detail  and 
illustrated  with  splendid  radiographs,  thus  adding  an  in- 


SINUSES  FOLLOWING  CERTAIN  OPERATIONS.  1  19 

structive  chapter  to  renal  surgery.1  My  experience  is 
limited  to  seven  cases,  six  of  which  were  cured  and  the 
seventh  died  subsequent  to  a  surgical  operation.  For 
illustration,  I  will  cite  four  of  these  cases,  including  the 
fatal  one: 

Case  1.  Cystic  Kidney  with  Calculi;  Operation;  Result,  Fatal. — 
Mrs.  H.  J.,  aged  about  50,  mother  of  two  healthy  children,  developed 
an  abscess  in  the  region  of  her  left  kidney  when  35.  The  abscess  was 
incised  and  suppurated  for  fifteen  years.  Besides  the  profuse,  puru- 
lent, and  malodorous  discharge,  she  passed  also  a  great  deal  of  pus 
in  the  urine.  December,  1907,  she  applied  to  me  for  treatment.  At 
that  time  I  had  very  little  experience  with  the  bismuth  paste,  but  I 
decided  to  try  it  in  this  case.  Following  the  injection,  the  discharge 
lessened,  but  the  radiograph  revealed  the  presence  of  calculi  in  the 
substance  of  the  kidney.  The  patient  was  in  many  ways  handicapped, 
having  only  one  kidney,  and  was  a  poor  subject  for  operation;  never- 
theless, nephrectomy  was  decided  on  and  performed.  It  was  very  dif- 
ficult to  separate  and  remove  this  large  sacculated  kidney  from  its 
firm  bed,  which  prolonged  the  operation.  The  kidney  had  been  en- 
tirely destroyed  and  consisted  of  a  large  mass  of  multilocular  abscesses 
studded  with  dark,  irregular-shaped  stones.  The  patient  died  on  the 
fourth  day  from  uremia.  It  is  my  belief  that  the  ether  anesthesia  was 
partly  responsible  for  the  uremia.  Bismuth  paste  treatment  could  have 
been  of  no  value  in  this  case  on  account  of  the  infected  calculi  within 
the  diseased  tissue. 

Case  2.  Tuberculous  Kidney;  Nephrectomy;  Sinuses  One  Year; 
Bismuth  Treatment;  Closure. — Mrs.  H.  R.,  aged  26,  was  operated  upon 
January  7,  1907,  by  Dr.  Carl  Beck  for  tubercular  right  kidney.  A 
tuberculous  involvement  of  the  bladder  and  urethra  made  it  impossible 
to  determine  before  the  operation  whether  the  left  kidney  was  func- 
tionating normally  and  whether  it  was  free  from  tuberculosis.  For 
this  reason  the  following  procedure  was  followed: 

The  right  kidney  was  brought  forward  and  fixed  outside  of  the 
body,  split,  and  all  the  urine  drained  outward,  whereupon  the  urine 
from  the  other  kidney,  which  was  voided  through  the  bladder,  was  so 
clear  that  we  could  conclude  that  the  nephrectomy  could  be  performed 
with  safety. '  It  required  a  large  incision,  and  the  ragged  cavity  which 
remained  after  removal  of  the  diseased  kidney  was  packed  with  gauze. 
After  long  and  tedious  treatment,  such  as  irrigation,  the  patient  im- 
proved in  general  health,  but  the  fistula  showed  no  tendency  to  heal- 
ing, and  the  patient  left  the  hospital  May  22,  nearly  six  months  after 
operation,    with   very   little    hope    that  her   fistula   would    ever    close. 


1  Heitz,  Boyer,  and  Morens:  Des  Injectiones  de  PatS  Bismuthee  en 
Chirurgie  Urinarie. — Annales  des  Maladies  des  Organs  Genito  Urinaries,  June 
1,  1910. 


120       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

About  three  months  later,  when  our  experiments  with  bismuth  injec- 
tions became  encouraging,  I  sent  for  her,  intending  to  try  this  method, 
with  the  view  of  closing  her  fistula.  She  returned  September  3,  1907, 
and  the  first  bismuth  injection  was  made,  of  which  we  have  a  skia- 
graph.    It  shows  that  the  fistula  reaches  up  to  the  diaphragm,  about 


Fig.  46.     Tuberculous  sinuses  of  kidney, 
nuses.      Vertebral  column  unaffected. 


A,  A    (for  tracing),   openings  of  si- 


four  and  one-half  inches  in  length.  From  September  3  until  November 
13  only  five  injections  were  made,  and  a  decided  improvement  followed. 
The  patient  did  not,  however,  wish  to  remain  longer  at  the  hospital, 
and  returned  once  a  week  for  bismuth  injections.  By  February  1, 
1908,  the  sinus  was  closed  and  remained  so.  The  closure  of  the  sinus 
js  not  quite  so  remarkable  a  feature  in  this  case  as  the  most  visual 


SINUSES  FOLLOWING  CERTAIN  OPERATIONS. 


121 


gain  in  weight.  In  her  worst  state,  in  September,  1907,  she  weighed 
ninety-one  pounds,  and  within  two  years  she  has  gained  sixty-four 
pounds,  and  is  in  perfect  health. 

Case  3.  Nephrectomy;  Sinus  Nine  Years;  One  Injection;  Closure  in 
Twenty-four  Hours. — Joe  L.  G.,  aged  46,  developed  an  abscess  in  his  left 
lumbar  region.  Incision  and  evacuation  of  one  quart  of  pus  relieved 
the  symptoms,  but  sinuses  remained.  Two  years  later  a  nephrectomy 
was  performed,  during  which  he  nearly  lost  his  life  from  hemorrhage. 


Fig.   4G  A.      Diagrammatic   illustration  of  Fig.   46. 


A  suppurating  sinus  remained,  and  the  drainage  was  kept  up  for  nine 
years.  The  opening  of  the  sinus  was  on  the  anterior  wall  of  the  abdo- 
men, about  three  inches  to  the  left  of  the  umbilicus,  but  led  subcuta- 
neously  to  the  kidney  region.  In  October,  1908.  he  came  for  examina- 
tion of  the  existing  post-operative  ventral  hernia.  I  injected  the  sup- 
purating sinus,  which  had  then  been  open  for  nine  years,  and  asked  the 
patient  to  return  next  day.  Within  these  twenty-four  hours  the  sinus 
closed  and  never  reopened.  Patient  gained  very  much  in  weight  and 
strength. 


122       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

The  following  case  is  instructive  for  diagnostic  as  well 
as  for  therapeutic  reasons: 

Case  4.  Tuberculosis  of  Kidney;  Sinus  Treated  Without  Nephrec- 
tomy; Cure. — Miss  C,  aged  19,  was  well  until  1907,  when  she  fell  from 
a  buggy  and  slightly  hurt  her  back.  After  two  months'  illness  of  fever, 
pain  in  the  back,  emaciation,  an  abscess  formed  in  the  lumbar  region. 
The  abscess  was  opened,  whereupon  secondary  infection  took  place. 
For  one  year  she  was  confined  to  bed,  running  a  temperature  from  one 


Fig.  47. 


Fig.  48. 


Figs.  47,  48.  Patient  with  tuberculous  kidney.  Fig.  47,  patient  in  most  emaci- 
ated state;  weight,  68  pounds.  Fig.  48,  patient  one  year  later;  weight,  129  pounds. 
Kidney  not  removed. 

to  three  degrees  every  day,  and  thus  was  reduced  to  a  mere  skeleton, 
weighing  only  seventy-six  pounds. 

July  16,  1908,  she  was  brought  to  me  in  this  pitiable  condition.  In 
the  eczematous  lumbar  region  were  two  sinuses,  secreting  quantities 
of  greenish  pus.  These  two  sinuses  communicated,  as  proven  by  the 
bismuth  injections.  On  account  of  the  painful  condition,  I  could  in- 
ject only  small  quantities  of  the  paste.  A  radiograph  proved  that  this 
case  was  a  tuberculosis  of  the  kidney,  the  vertebral  column  being  per- 
fectly normal. 


SLNU&LS  FOLLOWING  CERTAIN  OPERATIONS.         12.3 

Between  July  15  and  September  9  the  sinuses  were  injected  sixteen 
times  without  the  slightest  effect  upon  the  secretions  or  upon  her  gen- 
eral condition.  The  fever  continued.  On  September  9  I  used  a  lit- 
tle more  force  than  usual  during  the  injection,  and  felt  as  if  something 
had  given  way,  and  I  could  inject  three  times  the  usual  quantity. 
Another  radiograph  after  this  injection  (Fig.  46)  plainly  shows  that 
the  paste  reached  into  the  kidney.  From  that  day  the  temperature 
fell  to  normal,  the  secretion  changed  to  a  serous  consistency,  and 
after  five  subsequent  injections  the  sinuses  became  entirely  closed. 
The  patient  could  be  taken  into  the  fresh  air  in  a  rolling-chair  and 
began  to  gain  rapidly.  Fig.  47  shows  her  one  week  after  closure  of 
sinuses,  when  her  weight  was  only  sixty-eight  pounds.  Within  one 
year  her  weight  rose  to  one  hundred  and  twenty-nine,  which  she  has 
retained,  and  her  perfect  health  can  be  discerned  by  her  present  pho- 
tograph in  Fig.  48. 

Two  cases  similar  to  the  one  just  cited  were  reported 
by  Dr.  A.  J.  Ochsner  at  the  Chicago  Medical  Society, 
both  recovering  by  this  method  of  treatment. 

These  cases  show  that  sinuses  which  remain  after  spon- 
taneous rupture  of  kidney  abscesses  or  after  nephrec- 
tomy are  not  as  hopeless  a  condition  as  formerly  consid- 
ered, and  that  with  the  bismuth  treatment  the  outlook 
for  a  cure  is  most  promising. 


CHAPTER  IX. 

RECTAL  FISTULA— DIAGNOSIS  AND  TREAT- 
MENT WITH  BISMUTH  PASTE. 

The  bismuth  paste  serves  two  purposes  in  rectal  fis- 
tulae. First,  it  reveals  diagnostic  errors,  and,  second,  it 
heals  the  majority  of  cases  which  have  not  responded  to 
surgical  treatment.  I  have  encountered  several  cases  in 
which  the  radiographs  of  the  injected  fistulae  proved 
an  incorrect  diagnosis — they  were  sinuses  resulting  either 
from  pelvic  abscesses  or  tuberculous  osteomyelitis  of  the 
hip  or  sacrum.  These  abscesses  happened  to  rupture  so 
near  the  anus  that  they  were  mistaken  for  a  rectal  fistula 
and  operated  upon,  often  with  the  disastrous  result  of 
adding  an  incontinence  to  the  existing  trouble,  besides 
transposing  the  sinus  opening  from  the  skin  into  the  rec- 
tum.   Fig.  49  illustrates  such  a  case. 

The  therapeutic  results  depend  in  a  great  measure 
upon  correct  diagnosis  and  proper  teclmic.  A  fistula 
which  has  its  origin  in  a  tuberculous  focus  in  the  sacrum 
and  a  sequestrum  at  its  root  can  not  be  expected  to  heal 
by  simply  injecting  the  paste.  The  focus  of  the  disease 
must  first  be  eradicated.  If  the  fistula  has  a  counter- 
opening  in  the  rectum,  the  paste  will  flow  into  the  rectum 
by  the  shortest  route,  and  miss  side  branches  if  such 
exist. 

The  therapeutic  possibilities  of  the  paste  in  rectal 
fistulae  are  illustrated  in  the  following  case: 

Rectal  Fistulae,  Forty  Years'  Duration;  One  Injection;  Closure. — 
J.  P.,  aged  68,  developed  in  1868  a  pararectal  abscess.  Being  a  cow- 
boy, and  living  in  a  rural  district  where  a  physician  was  not  within 

124 


ltWJTAL  FIST  U  LA  K. 


125 


reach,  he  performed  his  own  surgical  operation  by  plunging  a  jackknife 
into  the  abscess  with  the  aid  of  a  mirror.  Within  one  year  he  bad 
five  sinuses  around  his  anus,  which  discharged  pus  uninterruptedly  for 
forty  years.  Although  many  times  advised  to  undergo  an  operation, 
he  refused,  preferring  daily  dressing,  to  which  he  so  accustomed  him- 
self that  he  did  not  mind  their  inconvenience. 

In  June,  1908,  I  first  injected  the  fistulas  with  bismuth  paste  (for- 
mula 1),  and  found  that  the  five  sinuses  communicated.  To  my  sur- 
prise, the  discharge  ceased  after  this  first  injection,  and  one  month 
later  all  sinuses  were  closed  and  have  remained  so  (two  years). 


1 

J5 

H 

\ 

" 

1 

A 

^j 

Pig.   49.      Rectal  fistula  originating  in  coccyx,  supposed  to  be  of  rectal  origin. 
A,  side  branch  ;  B,  highest  point,  near  coccyx. 


The  literature  contains  many  scattered  reports  of  cases 
of  rectal  fistula  treated  with  bismuth  paste,  and  the 
average  results  have  been  satisfactory.  Failures  in  treat- 
ment could  in  nearly  all  cases  referred  to  me  be  ac- 
counted for  in  two  ways— first,  faulty  technic,  and, 
second,  incorrect  anatomical  diagnosis. 

The  only  special  report  on  rectal  cases  is  that  of  Pen- 


126       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

nington,  who  tested  the  method  shortly  after  he  saw  my 
cases,  brought  before  the  Chicago  Medical  Society  in 
January,  1908.  His  report  relates  to  17  cases  which  he 
treated  with  bismuth  paste,  most  of  which  had  been  pre- 
viously treated  by  other  methods.  After  a  period  of  four 
months  he  obtained  a  cure  in  14  of  the  17  cases  (76.8  per- 
cent). Dr.  Pennington  modestly  attributes  this  high 
average  to  his  good  fortune  in  having  favorable  cases. 
My  explanation  would  be  that  his  large  percentage  of 
cures  was  due  to  following  out  the  technic. 

In  my  own  series  of  57  rectal  cases  4  were  given  up  as 
hopeless;  5  discontinued  treatment,  although  improved; 
48  were  cured,  3  of  which  had  recurrence  and  healed  with 
resumed  treatment.  One  patient  died,  three  years  after 
closure  of  the  fistula,  of  a  hemorrhage  of  his  lung.  There 
could  be  no  relation  established  between  the  cause  of  his 
death  and  the  former  rectal  trouble,  except  that  the 
fistula  had  been  of  tuberculous  nature. 

Technic  in  Rectal  Fistulse. 

The  patient  should  be  placed  in  the  knee-chest  posi- 
tion, and  the  sinus  opening  cleansed  with  95-percent 
alcohol.  The  metal  syringe  shown  in  Fig.  1,  filled  with 
the  paste,  is  then  immersed  in  hot  water,  so  as  to  keep 
the  paste  liquid.  The  tip  of  the  nozzle  is  placed  against 
the  opening,  and  with  steady,  gentle  pressure  the  paste 
is  injected  into  the  sinuses  until  the  patient  feels  some 
distention.  No  force  should  be  used.  In  order  to  as- 
certain whether  the  external  sinus  communicates  with 
the  rectum,  the  finger  should  be  introduced,  and,  if  it 
shows  traces  of  the  paste,  we  may  conclude  that  we  are 
dealing  with  a  complete  fistula.  Should  this  be  the  case, 
the  treatment  will  be  somewhat  difficult.  It  is  then  nec- 
essary to  occlude  the  internal  opening  of  the  fistula  with 


KKCTAL  FISTULAE. 


127 


the  finger  while  the  paste  is  being  injected  into  the  exter 
nal  opening.  Thus  the  escape  of  the  paste  into  the  rec- 
tum is  prevented  and  it  is  forced  into  the  other  direction, 
where  it  will  fill  other  existing  channels.  At  times  it 
becomes  necessary  to  employ  a  rectoscope  in  order  to  in- 
ject the  fistula  through  the  opening  within  the  rectum. 


Fig.   50.     Method  of  injection  of  external  rectal  fistula. 

For  this  purpose  the  long  nozzle  of  the  metal  syringe  is 
used.  It  must  be  kept  warm,  so  that  the  paste  will  not 
solidify  and  clog  the  narrow  channel.  "When  the  fistula 
has  a  very  small  opening  and  is  in  the  puckering  folds  of 
the  anus,  the  spear-shaped  tip  is  to  be  inserted,  while  an 
assistant  stretches  the  folds.  Fig.  50  illustrates  this  pro- 
cedure. 


128       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

After  the  injection  is  completed,  a  T-bandage  is  ap- 
plied and  the  dressing  changed  daily.  If  after  one  week 
the  discharge  continues  to  be  purulent,  the  fistula  should 
be  reinjected.  If  the  secretion  becomes  serous,  it  should 
not  be  reinjected,  as  it  will  usually  close  within  a  short 
period.     Fig.  50  illustrates  the  procedure. 


Fig.  51.      Dermoid  cyst  treated  with  bismuth  paste. 


An  infected  dermoid  cyst  of  the  sacrum  or  coccyx  may 
be  mistaken  for  a  rectal  fistula.  I  illustrate  such  a  case 
in  Fig.  51. 

In  this  picture  there  is  shown  the  procedure  of  injecting  a  sinus 
resulting  from  a  dermoid  cyst.  The  patient  is  only  23  years  old  and 
weighs  two  hundred  and  sixty  pounds.  For  the  past  five  years  he 
has  had  a  foul  discharge  from  four  little  openings,  one-half  inch  apart, 
in  the  fold  above  the  anus.  The  first  injection  proved  that  they  com- 
municated, because  the  paste  injected  in  one  at  once  escaped  from 


KKCTAI,    I' 1ST  I '  I, A  i;. 


129 


the  mouths  of  the  others.  At  one  time  a  small  quantity  of  jot-black 
hairs  came  out  of  one  of  the  openings.  This  indicated  that  we  had 
to  deal  with  a  dermoid  cyst,  and  consequently  an  operation  was  ad- 
vised and  performed,  which  consisted  in  the  complete  eradication  of 
the  cyst.  The  cavity  was  drained  and  four  days  later  an  injection  of 
the  paste  was  made.  The  purulent  and  foul  discharge  changed  into 
a  yellowish,  clear  serum  within  three  days,  and  healing  progressed 
rapidly.  This  picture  shows  that  a  greater  part  of  the  incision  is 
healed,  and  that  the  paste  injected  through  the  upper  opening  escapes 
through  the  lower.  Within  a  period  of  six  weeks  the  sinuses  were 
closed. 


Pig.   52.     Supposed  rectal  fistula,  shown  to  be  a  sinus  resulting  from  disease  of 
pelvic  organs.     A,  fistulous  opening  in  the  rectum  ;  B,  bi-paste  in  the  pelvic  cavity. 


The  following  case  is  typical  of  those  in  which  incor- 
rect diagnosis  led  to  futile  operations: 

Rectal  Fistula  Originating  in  the  Pelvis. — The  patient,  a  lady,  aged 
30,  has  since  1900  undergone  six  operations  for  rectal  fistula,  all  of 
which  failed  to  stop  the  profuse  and  irritating  pus  discharge.  The  last 
operation  was  very  extensive  and  produced  incontinence  of  feces.  In 
this  condition  the  patient  came  to  me  in  January.  1908.  when  I  made 
the  first  bismuth  paste  injection.  A  radiograph  (Fig.  52)  disclosed  that 
the  fistula  had  its  origin  high  up  in  the  pelvis.  Several  sinuses  as  high 
as  the  sacral  prominence  are  plainly  shown,  the  early  discovery  of 
which  could  have  saved  the  patient  the  six  operations  and  nine  years 


130       BISMUTH  TASTE  IN  CHRONIC  SUPPURATIONS. 

of  invalidism.  This  fact  was  corroborated  further  by  the  most  satis- 
factory result,  obtained  from  the  bismuth  paste  injection.  It  required 
three  months'  treatment,  but  the  sinuses  healed.  The  sinus  openings 
were  intrarectal,  and  the  large  gaping  rectal  opening  permitted  their 
being  easily  reached  and  injected.  A  year  after  the  cessation  of  dis- 
charge a  plastic  operation  for  the  incontinence  was  tried,  but  was  only 
partially  successful.  An  abdominal  operation  six  months  later  proved 
that  the  sinuses  originated  in  the  Fallopian  tubes. 

Examples  as  the  one  cited  above  must  guard  us  against 
assuming  that  every  suppurating  sinus  near  the  rectum 
is  necessarily  a  rectal  fistula. 

In  my  collection  of  radiographs  of  bismuth-injected 
rectal  fistulae  there  are  a  number  of  examples  in  which 
the  supposed  rectal  fistula  was  in  fact  a  sinus  originating 
in  some  distant  part  of  the  body,  such  as  the  hip  joint  or 
spine.  In  not  a  single  one  of  them  have  I  seen  a  straight 
fistula,  similar  to  the  schematic  drawings  of  our  text 
books.  In  the  radiograph  shown  in  Fig.  53  I  illustrate  a 
sinus  in  which  the  passing  of  a  probe  indicated  that  we 
had  to  deal  with  one  single,  straight  fistula,  and,  behold, 
a  turtle-shaped  sinus,  so  different  from  what  we  ex- 
pected, reveals  itself. 

This  demonstrates  the  fallacy  of  relying  upon  the 
probe  as  an  anatomical  diagnostic  guide.  We  can  not 
rely  upon  its  accuracy  in  showing  us  the  direction,  depth, 
and  extent  of  a  fistula.  The  mere  fact  that  the  probe 
will  pass  readily  into  a  fistula  is  no  proof  that  it  has 
reached  its  depth,  or  that  the  sinus  has  no  branches;  and, 
on  the  other  hand,  if  the  probe  is  arrested  in  some  fold 
or  curve,  it  likewise  fails  as  a  diagnostic  aid.  In  many 
instances  its  use  is  very  deceptive,  and  has  led  to  errors 
which  have  caused  many  a  useless  operation.  The  diag- 
nostic method  by  means  of  the  bismuth  paste  has,  in  my 
hands,  entirely  displaced  the  use  of  the  probe  for  sound- 
ing fistulae. 

We  must  bear  in  mind  the  fact  that  a  fistula  is  noth- 


RECTAL  FISTULAE.  13] 

ing  more  than  a  shriveled  old  abscess  cavity,  and  not, 
as  is  often  supposed,  a  channel  formed  by  an  ulcerative 
process  from  the  surface,  burrowing  into  the  depth  of  the 
tissues.     At  times  the  abscess  is  multil ocular  and   will 


Fig.  53.     Turtle-shaped  sinus  in  perineal  region,  thought  to  be  a  straight  rectal 
fistula. 

undermine  a  large  area  in  the  perineum,  and  thus  an 
irregular  network  of  fistulous  tracts  may  surround  the 
rectum  and  form  a  number  of  sinus  openings  around  the 
anus. 

•  The  stereoscopic  radiographs,  of  which  I  have  shown 
a  number  among  my  illustrations  in  Professor  Kelly's 
Stereo-clinic,  have  shed  a  great  deal  of  light  upon  the 
anatomical  relations  of  the  sinus  tracts  to  the  surround- 
ing structure,  and  have  cleared  up  for  me  many  fallacies 
in  both  diagnosis  and  treatment  of  rectal  fistulae. 


CHAPTER  X. 
BISMUTH  PASTE  IN  FECAL  FISTULA. 

Fecal  fistulse,  such  as  result  from  laparotomies,  have 
the  tendency  to  spontaneous  closure.  At  times,  however, 
their  persistence  causes  the  patient  such  misery  that  he 
is  willing  to  submit  to  the  most  hazardous  operations.  It 
is,  therefore,  comforting  to  know  that  this  class  of  fistulse 
can  also  be  successfully  treated  with  bismuth  paste.  Be- 
sides several  successful  cases  reported  in  medical  litera- 
ture by  others,  we  have  treated  eight  cases  at  the  North 
Chicago  Hospital,  five  of  which  were  cured,  one  failed  be- 
cause of  a  coexisting  intra-abdominal  tumor,  and  two 
died  as  a  result  of  tuberculous  peritonitis,  which  was  the 
cause  of  the  fecal  fistula. 

The  result  obtained  in  the  first  case  in  which  the  paste 
was  tried  was  so  striking  that  I  felt  encouraged  in  its 
further  application  in  similar  cases.  The  history  of  this 
first  case  is  as  follows: 

Fecal  Fistulae;  Bismuth  Injection;  Closure. — M.  A.,  aged  25;  family 
history  nontubercular.  In  the  fall  of  1905  he  was  operated  upon  for 
gangrenous  appendicitis.  Fecal  fistula  resulted  and  persisted  for  four 
months.  A  second  operation  failed  to  close  the  fistula.  He  was  then 
treated  for  six  months  with  silver  nitrate  cauterization,  without  im- 
provement. In  August,  1906,  we  took  a  radiograph  after  an  injection 
of  bismuth  paste.  It  demonstrated  the  uselessness  of  our  silver  nitrate 
treatment  because  of  the  existence  of  a  cavity,  which  undermined  the 
muscles  to  an  area  two  inches  in  diameter.  The  first  injection  was 
sufficient  to  obliterate  this  fistula.  Two  years  later  finds  the  fistula 
still  closed. 

A  second  case  with  almost  the  identical  history,  in 
which  the  fecal  fistula  had  persisted  for  one  year,  reacted 
also  most  favorably  to  the  bismuth  treatment. 

132 


FECAL  FISTULAE.  133 

The  following  case  gives  an  idea  of  the  possibilities  of 
the  bismuth  paste  in  fecal  fistula?. 

Fecal  Fistula;  Discharging  Entire  Bowel  Contents. — Mrs.  J.,  aged 
29,  was  operated  on  July  17,  1909,  for  double  pyosalpinx.  The  diseased 
tubes  were  so  adherent  to  the  intestines  that  during  their  removal  the 
large  bowel  was  torn.  The  sutures  did  not  heal,  the  bowel  reopened, 
and  for  three  months  the  entire  fecal  contents  discharged  through  the 
abdominal  wound,  no  fecal  matter  or  gas  passing  through  the  rectum. 
There  being  no  natural  tendency  to  closure,  it  was  decided  to  resect 
a  portion  of  the  bowel,  to  which  the  patient,  who  was  tired  of  her  mis- 
erable existence,  gladly  consented.  Before,  however,  resorting  to  this 
dangerous  operation  I  decided  to  try  a  few  injections  of  bismuth  paste, 
and,  although  I  did  not  expect  very  much  from  its  use,  the  change  was 
most  surprising.  The  large  opening  gradually  contracted  to  a  narrow 
channel,  the  patient  began  to  have  a  small  evacuation  from  the  rectum, 
and  within  ten  weeks  the  fistula  was  entirely  closed.  Ten  days  later  a 
pin-hole  opening  appeared  and  small  amount  of  gas  escaped.  At  pres- 
ent sinus  is  closed.     Patient  gained  forty  pounds. 

This  remarkable  result  in  one  case  should  not,  how- 
ever, create  the  impression  that  every  fecal  fistula  can  be 
cured  by  this  method.  The  anatomical  conditions  in 
themselves  make  the  prospects  of  a  cure  uncertain.  I 
believe  that  the  percentage  of  cases  suitable  for  the  bis- 
muth treatment  will  be  smaller  than  those  of  rectal  fis- 
tula?. 

Dr.  Cuthbertson,  of  Chicago,  in  reporting  a  case  of 
post-operative  fecal  fistula  cured  with  the  paste,  made  a 
practical  suggestion.  He  states:  "It  is  absolutely  neces- 
sary for  the  patient  to  remain  in  bed  during  the  period 
of  treatment.  If  he  is  allowed  to  walk  about,  the  paste  is 
immediately  expelled  either  by  the  contraction  of  the  ab- 
dominal muscles  or  the  pressure  of  the  bowel  contents." 

Our  experience  in  treating  these  fecal  fistula?  may  be 
summed  up  as  follows: 

1.  Where  the  fistula  is  the  result  of  tuberculous  peri- 
tonitis or  intestinal  tuberculosis,  the  bismuth  treatment 
will  be  useless. 

2.  The  post-operative  fecal  fistula?  are  best  suited  for 


134       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

this  treatment,  but  a  reasonable  length  of  time  should  be 
allowed  for  spontaneous  closure,  and  in  no  instance 
should  the  paste  be  poured  into  the  fresh  wound  in  the 
abdomen. 

3.  The  cases  in  which  the  channel  leading  to  the  intes- 
tine is  long  and  narrow  respond  most  favorably  to  this 
treatment,  as  the  paste  blocks  up  the  fistula,  keeps  the 
fecal  masses  from  soiling  it,  and  thus  a  most  favorable 
condition  for  healing  is  produced.  The  fecal  contents 
will  then  be  propelled  through  the  intestinal  tract. 

4.  When  the  channel  between  the  bowel  and  the  skin 
surface  is  short,  or  when  the  intestines  protrude,  the 
paste  is  absolutely  useless,  a  surgical  operation  then  be- 
ing the  only  means  of  producing  a  cure. 


CHAPTER  XI. 

BISMUTH  PASTE  TREATMENT  OF  EMPYEMA 
AND  LUNG  ABSCESS. 

Without  dwelling  upon  the  usual  methods  of  treatment 
of  empyema  and  lung  abscess,  I  desire  to  describe  this 
new  method  which  is  applicable  especially  to  those  cases 
in  which  other  surgical  treatment  has  failed. 

The  bismuth  paste  may  be  applied  in  chest  cases  for 
diagnostic  and  therapeutic  purposes.  As  a  diagnostic 
aid  it  has  served  most  satisfactorily  in  outlining  the  con- 
tour and  estimating  the  size  of  suppurative  cavities  with- 
in the  pleural  space.  The  radiographs  showing  the 
boundaries  of  these  injected  cavities  aid  in  differentiat- 
ing between  an  empyema  of  pleural  origin  and  one  re- 
sulting from  a  rupture  of  a  lung  abscess  into  the  pleura. 

As  a  therapeutic  agent  the  paste  has,  in  a  certain  class 
of  cases,  proven  to  be  the  remedy  par  excellence.  Its 
chief  value  lies  in  producing  rapid  closure  of  old  sinuses 
of  empyema,  some  of  which  had  persisted  in  discharging 
pus  for  many  years  in  spite  of  the  most  radical  surgical 
treatment,  such  as  the  Estlander  or  Schede  operation. 

Ample  time  has  now  elapsed  and  a  sufficient  number  of 
reports  from  reliable  sources  in  Europe  and  America 
have  appeared  in  medical  literature  to  justify  the  con- 
clusions as  to  the  real  value  of  this  new  treatment. 

In  December,  1907,  I  first  instituted  this  form  of  treat- 
ment in  empyema,  an  abstract  of  a  report  of  the  first  case 
being  here  cited : 

Case  1.  Empyema. — A.  H.,  aged  19;  family  and  personal  history 
free  from  tuberculosis.     January,  1907,  attack  of  pleurisy  with  effusion. 

135 


136       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

soon  changing  into  empyema.  March  20,  1907,  resection  of  two  ribs, 
evacuation  of  pus,  and  drainage.  A  daily  discharge  of  two  or  three 
ounces  of  fetid,  green  pus  persisted  in  spite  of  all  treatment.  Decem- 
ber 20,  1907,  the  patient  was  brought  to  me  for  treatment. 

Bismuth  Treatment. — Drainage  tube  was  removed  and  120  grams 
of  bismuth-vaselin  paste  were  injected  into  the  suppurating  cavity  in 
the  patient's  chest.  Two  days  later  the  injection  was  repeated,  most 
of  the  previously  injected  paste  having  escaped  with  the  discharging 
pus.  After  four  days  the  discharge  became  serous,  lost  its  foul  odor, 
and  greatly  diminished  in  quantity.  Injections  were  repeated  daily, 
and  on  the  twelfth  day  the  sinus  closed  and  has  remained  so.  The 
patient  has  gained  thirty  pounds  in  weight  and  is  in  perfect  health. 

Skiagraphs  had  been  taken  at  intervals  of  two  months,  which 
demonstrated  the  gradual  absorption  of  the  bismuth  paste  and  the 
slow  expansion  of  the  lung  where  the  abscess  had  existed. 

This  surprising  result  obtained  by  such  simple  means 
naturally  encouraged  its  further  application,  and  six 
months  later  I  was  able  to  include  in  my  report  to  the 
Sixth  International  Congress  on  Tuberculosis  nineteen 
cases  of  empyema  and  lung  abscesses  which  had  been 
treated  by  this  method.  Fourteen  of  these  cases  were 
then  apparently  cured,  four  improved  and  still  under 
treatment,  and  one  not  improved — treatment  discon- 
tinued. 

The  sources  of  this  report  were  perfectly  reliable,  such 
competent  surgeons  as  Mayo,  Ochsner,  McGuire,  and 
others  having  contributed,  in  addition  to  the  cases  treated 
by  myself. 

Since  the  publication  of  these  cases  reports  from  many 
surgeons  throughout  this  country  and  from  abroad  have 
convinced  me  that  the  application  of  the  bismuth  paste 
in  the  treatment  of  empyema  surpasses  even  the  good  re- 
sults obtained  in  treating  other  suppurative  conditions 
by  the  bismuth  paste  method. 

Nemanoff,  for  instance,  reports  from  the  clinic  of  Pro- 
fessor Kacljan,  St.  Petersburg,  four  cases  of  empyema  in 
which  one  injection  of  bismuth  paste  in  each  case  was 
sufficient  to  produce  complete  closure,  whereas  the  same 


EMPYEMA  AND  LUNG  ABSCESS.  137 

patients  had  been  treated  at  the  clinic  for  six  months  by 
other  methods  without  success.  Vidakovich  reports  two 
cases  of  empyema,  both  with  perfect  result. 

Dr.  A.  J.  Ochsner,  Chicago,  reported  to  the  American 
Surgical  Association  on  June  4,  1909,  fourteen  cases  of 
empyema,  all  of  which  had  been  previously  operated 
(two  by  Estlander's  operation),  with  sinuses  in  all  cases 
persisting  nevertheless.  He  applied  the  bismuth  paste 
in  each  of  these  cases  with  the  result  that  twelve  cases 
healed  completely,  and  two  were  still  under  treatment 
and  very  much  improved. 

My  experience  pertains  to  nineteen  cases  of  empyema 
and  eight  cases  of  lung  abscesses  treated  by  the  bismuth 
paste  method. 

At  first  I  employed  the  paste  in  cases  of  drained  em- 
pyema only,  but  later  its  usefulness  was  extended  to  cases 
of  empyema  still  unopened  and  to  abscesses  within  the 
lung  tissue  proper.  Of  these  cases  I  shall  cite  a  few, 
such  as  will  illustrate  some  special  points  in  the  technic 
not  mentioned  in  the  general  rules  and  aid  in  the  selec- 
tion of  cases  to  which  this  form  of  treatment  may  be  ap- 
plied advantageously. 

Technic  in  Chest  Cases. 

The  technic  of  bismuth  injections  employed  in  abscess 
cavities  in  the  chest  differs  somewhat  from  that  applied 
in  the  sinuses.  In  the  chest  we  have  to  deal  with  an  in- 
fected cavity  which  has  a  rigid  chest  wall  on  one  side, 
and  the  retracted,  but  more  or  less  resilient,  lung  on  the 
other. 

A  radiograph  of  the  chest  is  first  taken.  The  discharge 
should  be  examined  microscopically,  cultures  made,  and 
where  tuberculosis  is  suspected  a  guinea  pig  should  be 
inoculated.     The  cavity  should  then  be  filled  by  means 


138       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

of  a  glass  syringe  with  a  33-percent  bismuth  paste,  but 
no  drainage  tube  inserted,  and  then  another  radiograph 
taken,  which  will  show  the  outline  of  the  cavity. 

It  is  not  advisable  to  leave  more  than  100  grams  of  a 
33-percent  paste  in  the  cavity  longer  than  three  days. 
When  more  than  100  grams  are  required  to  fill  the  cavity, 
and  none  of  the  injected  paste  has  escaped  during  the  fol- 
lowing twenty-four  hours,  it  is  advisable  to  remove,  either 
by  suction  or  by  flushing  with  olive  oil,  such  quantity  as 
will  leave  approximately  100  grams  in  the  pleural  cavity. 
In  case  the  entire  injected  quantity  has  escaped  into  the 
dressings,  a  second  injection  should  be  made  with  a  10- 
percent  bismuth  paste  in  order  to  keep  the  hollow  pleural 
space  filled  with  a  semi-solid  sterile  substance. 

Gauze  dressing  is  changed  daily  until  the  sinus  closes. 
Should  the  temperature  rise  above  101°  F.,  or  the 
patient  complain  of  severe  pressure,  the  accumulated 
fluid  should  be  drained  off.  If  the  temperature  remains 
normal,  and  the  amount  of  paste  injected  is  not  more  than 
100  grains,  it  may  be  left  in  for  absorption,  provided  no 
signs  of  bismuth  intoxication  arise.  Repetition  of  the  in- 
jection is  necessary  only  when  the  microorganisms  are 
still  present  in  the  secretions,  and  therefore  a  systematic 
examination  of  same  is  necessary. 

Negative  Pressure  for  Re-expansion  of  the  Lung". 

At  the  suggestion  of  Dr.  Carl  Beck  I  have  recently  em- 
ployed a  means  for  reexpansion  of  contracted  lung.  The 
technic  is  here  illustrated: 

M.,  aged  31,  developed  in  1900  acute  pleurisy,  terminating  in  em- 
pyema. After  several  tappings  of  fluid,  drainage  with  a  rubber  tube 
was  established.  The  empyema  proved  to  be  of  tubercular  origin,  the 
bacilli  having  constantly  been  found  in  the  pleural  discharge.  For 
the  past  nine  years  the  cavity  had  been  flushed  daily  with  antiseptic 
solutions  and  drainage  maintained. 


EMPYEMA  AND  LUNG  ABSCESS. 


i:{9 


On  January  10,  1910,  the  first  bismuth  paste  injection  was  made, 
but  the  cavity  was  not  entirely  filled,  only  240  grams  being  injected. 
The  secretion,  which  up  to  this  time  had  been  purulent,  soon  became 
serous  and  sterile,  but  there  was  no  indication  of  reexpansion  of  lung. 

The  following  method  was  applied  and  found  satisfac- 
tory (Fig.  54) : 


Fig,   54.     Method  of  re-expansion  of  lung  by  suction  pump. 


The  rubber  tube  (A),  which  is  fastened  to  a  rubber 
nipple  (B),  is  inserted  into  the  sinus  and  this  is  covered 
by  a  Bier's  cup.  To  the  outlet  of  the  Bier's  cup  is  at- 
tached the  connecting  tube  (C)  of  a  large  suction  syringe 
which  has  a  release  valve.     Moderate  suction  is  produced 


140       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

and  released  in  the  rhythm  of  the  patient's  breathing. 
During  inspiration  we  produce  suction;  during  expira- 
tion we  release  the  valve  and  allow  the  lung  to  collapse. 
This  treatment  is  carried  on  systematically  every  day  for 
five  or  ten  minutes. 

This  is  suitable  in  cases  where  the  discharge  is  not  pro- 
fuse or  bloody.  In  some  cases  the  granulating  surface 
is  very  apt  to  bleed  when  strong  suction  is  applied,  which 
fact  should  always  be  borne  in  mind. 

In  the  case  here  illustrated  we  have  watched  the  grad- 
ual expansion  of  the  lung.  When  beginning  the  treat- 
ment the  cavity  would  hold  over  240  grams  of  the  paste, 
while  it  now  overflows  when  injecting  but  45  grams.  The 
physical  signs  and  radiographs  give  evidence  of  the  lung 
expansion. 

Large  Cavity  Remaining  After  Estlander  Operation. 

In  Fig.  55  we  show  the  cavity  left  in  the  pleura  after  a 
secondary  Estlander  operation  on  a  young  man  26  years 
old.  After  two  years  of  constant  suppuration  the  bis- 
muth paste  treatment  was  instituted.  The  secretion  be- 
came sterile,  but  the  lung  remained  retracted.  I  em- 
ployed the  suction  pump  treatment  described  in  this 
chapter,  and  within  six  weeks  the  cavity  was  reduced  to 
half  its  size,  holding  only  nine  ounces  at  present. 

The  following  cases  are  cited  to  illustrate  the  bismuth 
paste  treatment  of  chest  cases: 

Case  4.  Simple  Empyema. — Chas.  L.,  aged  18,  had  the  grip  in 
March,  1908;  two  weeks  later  pleurisy,  with  effusion;  temperature, 
105°.  Four  weeks  later  aspiration,  resection  of  a  rib,  and  evacuation 
of  2,000  cubic  centimeters  of  pus,  and  drainage.  For  the  next  three 
months  discharge  profuse.  July  20,  1908,  30  grams  of  bismuth  paste 
were  injected,  and  within  twenty-four  hours  the  discharge  ceased  and 
the  sinus  closed  five  days  later.  Patient  gradually  regained  his  health 
and  sinus  has  not  reopened. 

Case  6.     Empyema  of  Spontaneous  Rupture,  Leaving  Three  Sinuses. 


EMPYEMA  AND  LUNG  ABSCESS. 


141 


— Mary  H.,  aged  8,  at  the  age  of  6  developed  an  empyema,  which,  after 
several   months   of   expectant   medical   treatment,    ruptured    spontane- 
ously in  two  places  on  the  anterior  chest  wall,  leaving  three  sinui  i 
discharging  thick  pus.     Child  was  very  much  emaciated  when  brought 
to  me  in  May,  1908.     Fever  rose  to  101°  or  102°  daily.     Patient,  coughed 


Fig.   55.     Cavity  in  pleura  remaining  after  Estlander  operation, 
bismuth  paste. 


Injected  with 


and  had  shortness  in  respiration  (20  to  42).  There  was  dullness  over 
the  entire  left  chest,  radiograph  distinctly  showing  the  left  side  filled 
with  fluid.  Instead  of  the  usual  resection  of  ribs  and  drainage.  I  in- 
jected 60  grams  of  bismuth  paste  through  one  of  the  sinuses.  Temper- 
ature and  cough  persisted  in  a  milder  form  for  three  weeks;  there- 
after all  symptoms  disappeared  and  all  sinuses  closed.     Two  years  have 


142       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

elapsed,  .fluid  has  disappeared,  child  has  gained  thirty  pounds,  and  is 
in  perfect  health. 

Bacteriologic  examination  of  pus,  carried  out  systematically,  proved 
that  the  pus  discharge  became  sterile  twenty  days  after  first  injection. 

Case  7.  Empyema;  Two  Years'  Drainage;  Permanent  Closure  After 
First  Paste  Injection. — Miriam  D.,  a  delicate  child,  aged  5%,  at  the 
age  of  3  developed  an  acute  lobar  pneumonia.  Empyema  followed, 
and  after  aspiration  of  the  pus  two  ribs  were  resected.  Discharge  of 
pus  continued  for  one  and  one-half  years,  child  gradually  failing  in 
health.  As  a  last  resort  an  Estlander  operation  was  advised  by  the 
physician  in  charge,  to  which  the  parents  did  not  consent.  In  October, 
1908,  the  child  was  brought  to  me  for  treatment.  Temperature  from 
99°  to  101°.  Extreme  emaciation,  cough  with  pain,  as  well  as  retrac- 
tion of  the  chest  wall,  were  the  principal  symptoms.  The  small  open- 
ing in  the  chest  secreted  daily  about  30  grams  of  creamy  pus. 
Through  this  sinus  I  injected  30  grams  of  bismuth  paste.  A  radio- 
graph showed  that  the  cavity  contained  a  large  quantity  of  pus,  and 
that  the  paste  merely  floated  therein.  Although  no  further  injections 
were  made,  I  observed  a  gradual  decrease  in  the  fever  and  cough, 
cessation  of  the  discharge,  and  closure  of  the  sinus  on  the  tenth  day. 
The  child  gained  four  pounds  in  two  weeks  and  now  has  regained  per- 
fect health.  This  patient  was  presented  by  Dr.  Hartford  at  the  session 
of  the  American  Medical  Association,  Atlantic  City,  June,  1909. 

The  lesson  learned  from  cases  6  and  7  is  the  following: 

1.  That  it  is  not  absolutely  necessary  to  evacuate  or 
drain  off  the  pus  from  the  pleural  cavity  before  injecting 
the  bismuth  paste,  and  that  small  quantities  (30  to  60 
grams)  are  sufficient  to  produce  the  desired  results. 

2.  Although  the  purulent  exudate  was  not  absorbed 
for  several  weeks  after  the  bismuth  injections,  its  pres- 
ence caused  no  elevation  of  temperature,  and  sinuses 
closed  in  a  comparatively  short  time. 

3.  While  the  discharge  retained  its  purulent  character 
after  the  bismuth  injections,  it  was  nevertheless  found  to 
be  sterile. 

Case  9.  Empyema;  Twenty-eight  Years'  Drainage;  Closure  with  Bis- 
muth Paste. — G.  T.,  aged  39;  engineer;  family  history  negative.  In 
1881  he  suffered  from  an  attack  of  pneumonia,  followed  by  an  accu- 
mulation of  pus  in  the  left  pleura.  Drainage  was  established  by  inter- 
costal incision  (Dr.  Favill,  Sr.,  Madison,  Wis.),  and  rubber  tubing  in- 
serted.    The  purulent  discharge  had  persisted  since  1881,  with  only  a 


EMPYEMA  AND  LUNG  AIJKGKSS.  14.5 

few  days'  intermission,  a  drainage  tube  being  kept  in  the  discharging 
sinus  for  twenty-eight  years.  Various  methods,  except  radical  opera- 
tions, were  tried  in  attempts  to  close  the  sinus,  but  all  failed.  In 
January,  1909,  the  patient  was  referred  to  me  by  Dr.  H.  B.  Favill  for 
treatment.     His  general  health  was  very  good,  temperature  and  pulse 


Pig.   56.      Empyema  of  twenty-eight    years'    duration, 
paste.     Closure  in  sixty  days. 


Injected    with    bismuth 


normal,  right  lung  normal,  left  lung  and  chest  cavity  very  much  con- 
tracted; pus  discharge  thick  and  of  dark-green  color,  containing 
staphylococci  and  a  few  streptococci. 

Bismuth  Treatment. — Injection  of  bismuth  paste  (formula  No.  1),  60 
grams  filling  out  the  entire  contracted  pus   cavity.     Temperature   re- 


144       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

mained  normal,  and  discharge  became  serous  on  fifth  day.  After 
sixty  days  the  sinus  closed,  and  patient  returned  to  Arizona  to  resume 
his  work.     There  is  no  recurrence. 

This  case  is  very  instructive,  as  it  teaches  that  even 
after  twenty-eight  years'  constant  suppuration  an  em- 
pyema may  be  obliterated  by  injection  of  the  paste. 
The  radiograph  (Fig.  56)  shows  the  size  and  contour  of 
the  remaining  pouch,  and  likewise  illustrates  the  efforts 
of  nature  in  her  attempt  to  obliterate  the  pus  cavity. 
The  ribs  are  so  much  retracted  that  the  intercostal  spaces 
are  nearly  obliterated,  the  spinal  column  is  markedly 
curved,  with  its  convexity  to  the  well  side,  the  clavicle 
drawn  downward  and  diaphragm  drawn  upward;  all 
structure  contracting  toward  one  central  point — the  old 
suppurating  cavity. 

Case    12.     Empyema    of    Infant    Injected    with    Bismuth    Paste. — M., 

aged  2,  had  a  severe  attack  of  pneumonia  April  16,  1909;  temperature, 
105°;  pulse,  136;  respiration,  48;  after  ten  days  developed  into  an  em- 
pyema. Resection  of  rib  by  Dr.  Carl  Beck;  drainage.  Temperature 
still  rising  to  100°  to  102°  daily;  respiration,  38  to  48. 

Bismuth  Treatment. — On  the  eighth  day  after  the  operation  an  in- 
jection of  120  cubic  centimeters  of  a  5-percent  bismuth-vaselin  paste 
was  made,  and  two  days  later  the  same  quantity  was  again  injected. 
Temperature  fell  to  99.4°  (rectal),  respiration  to  30.  The  pus  became 
sterile  after  the  first  bismuth  injection,  but  staphylococci  reappeared 
a  week  later,  and  for  this  reason  the  opening  was  not  allowed  to  close. 
The  injections  were  continued  for  three  weeks  until  the  secretion  be- 
came sterile.     Sinus  closed,  and  child  is  perfectly  well. 

Tuberculous  Empyema. 

It  is  noteworthy  that  the  tuberculous  empyema  is  far 
more  resistent  to  any  form  of  treatment  than  that  of 
pneumococcus  or  other  origin.  Murphy  states  that  a 
very  large  percentage  of  empyemas  in  adults  is  of  the 
tuberculous  form,  and  that  these  rarely  undergo  absorp- 
tion or  break  into  a  bronchus. 

From  personal  communication  with  Dr.  Moore,  medical 


EMPYEMA  AND  LOTG  ABSCESS.  145 

superintendent  of  the  Dunning  Hospital  for  Consump 
tives,  an  institution  which  takes  care  of  an  average  of 
four  hundred  consumptives  in  the  most  advanced  stages, 
I  have  the  information  that  in  the  past  four  years  he 
observed,  in  5,000  cases  treated,  25  cases  of  tuberculous 
empyema,  and,  whether  operated  on  or  not,  all  of  the 
patients  succumbed  to  the  disease. 

These  cases  usually  start  with  serofibrinous  pleurisy, 
which,  either  from  frequent  tapping  or  spontaneously, 
become  secondarily  infected  and  result  in  empyema.  Op- 
eration is  usually  resorted  to,  and  as  a  rule  the  subse- 
quent treatment  is  very  tedious  and  unsatisfactory. 

In  my  series  of  cases  of  empyema  three  proved  to  be  of 
tuberculous  origin,  and,  while  I  do  not  consider  them  per- 
fectly cured,  they  have  regained  their  health  sufficiently 
to  permit  of  the  resumption  of  their  usual  occupations. 

Empyemas  in  children,  or  those  following  acute  pleu- 
ritis  in  adults,  give  a  much  brighter  outlook  for  recovery. 
In  children  the  expansion  of  the  lung  and  spontaneous 
closure  of  the  sinus  is  rapid,  and  the  majority  of  cases  of 
the  nontuberculous  type  in  adults  will  yield  to  the  simple 
drainage.  A  small  percentage  of  cases,  however,  resist 
all  medical  and  surgical  treatment,  and  sinuses  will  per- 
sist in  discharging  pus  indefinitely.  The  failures  may 
be  explained  as  follows: 

1.  As  long  as  the  walls  lining  the  abscess  cavity  are  the 
seat  of  living  microorganisms,  especially  tubercle  bacilli. 
an  obliteration  of  the  space  can  not  be  expected. 

2.  After  years  of  suppuration  the  pleura  has  become 
hard  and  leathery,  binding  down  the  cicatrized  lung,  and 
thus  the  expansion  of  the  lung  is  not  possible. 

The  requirements,  therefore,  are:  a  cavity  free  from 
microorganisms  and  the  lung  still  sufficiently  resilient  for 
expansion. 


146       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

The  method  described  and  employed  in  my  cases  pos- 
sesses, I  believe,  to  a  marked  degree  the  means  essential 
to  obliteration  of  empyema.  The  introduction  of  bismuth 
paste  has  as  a  rule  produced,  by  a  process  of  local  leuco- 
cytosis,  a  sterilization  of  the  cavity,  and  in  most  cases 
softened  the  indurated  pleura  sufficiently  to  allow  mod- 
erate expansion  of  the  lung  and  the  obliteration  of  the 
space. 

Lung  Abscess. 

It  is  needless  to  say  that,  in  order  to  cure  lung  abscess, 
an  operation  is  necessary.  I  suggest  two  valuable  aids 
in  the  procedure — namely,  the  stereoradiograph  for 
diagnosis,  and  the  bismuth  paste  for  the  after-treatment. 

The  stereoradiograph  is  a  most  valuable  guide  in  the 
diagnosis.  It  will  define,  in  plastic  form,  the  boundaries 
of  the  abscess,  thus  enabling  the  surgeon  to  reach  it  by 
the  shortest  route.  It  will  also  locate  foreign  bodies, 
which,  at  times,  are  the  cause  of  the  abscess. 

The  bismuth  paste  is  a  valuable  adjunct  in  the  after- 
treatment.  Instead  of  draining  the  abscess  for  weeks 
or  months,  or  flushing  it  with  various  antiseptic  solu- 
tions, it  is  filled  with  the  paste  the  second  day  after  the 
operation.  This  promotes  the  sterilization  of  the  cavity, 
the  odor  soon  disappears,  and  the  cavity  tends  toward 
contraction  and  final  obliteration. 

It  is  noteworthy  that  such  cases  heal  in  a  very  short 
time,  even  when  the  cavity  communicates  with  a 
bronchus.  The  following  case  illustrates  this  new 
method  of  treatment : 

Case  5.  M.  M.,  aged  42.  One  year  ago,  after  a  short 
illness  of  cough  and  fever,  he  suddenly  felt  a  large  quan- 
tity of  fluid  rising  in  his  throat,  which  almost  strangled 
him.     It  was  the  rupture  of  a  lung  abscess.     From  that 


EMPYEMA  AND  LUNG  ABSCESS.  147 

time  on  he  continually  expectorated  from  ten  to  twelve 
ounces  of  very  offensive  pus  every  morning. 

Diagnosis. — May  13,  1910.  A  stereoradiograph  dem- 
onstrated the  lung  abscess  to  be  located  in  the  right  lower 
lobe,  corresponding  to  the  posterior  aspect  of  the  eighth, 
ninth,  and  tenth  ribs.  The  stereoscopic  view  showed 
plainly  that  the  abscess  was  not  superficial,  and  that  at 
least  a  two-inch  thickness  of  lung  tissue  existed  between 
the  pleura  and  the  abscess  wall.  Physical  examination 
by  Professor  Babcock  corroborated  the  findings  of  the 
radiograph. 

New  Method  of  Treatment. — The  following  surgical, 
two-step  operation,  which  I  had  previously  carried  out  in 
two  similar  cases,  was  employed.  Under  general  anes- 
thesia, through  a  trap-door  incision,  three  inches  of  each 
of  the  tenth  and  eleventh  ribs  in  line  with  the  abscess 
were  resected.  The  costal  pleura  was  cleared  of  all  ad- 
herent tissue,  so  that  a  circular  area  three  inches  in  diam- 
eter was  exposed.  Without  incising  the  pleura,  the  ex- 
posed surface  was  swabbed  with  a  small  quantity  of  95- 
percent  carbolic  acid.  Into  this  cauterized  area  a  flat  coil 
of  No.  14  red  rubber  tubing  was  placed,  and  the  skin 
wound  closed  with  temporary  sutures.  The  object  of  the 
carbolic  cauterization  of  the  costal  pleura  was  to  produce 
its  rapid  adhesion  to  the  opposite  surface  of  the  lung. 
By  this  procedure  two  important  aims  are  attained: 

1.  The  adhesion  protects  the  pleural  cavity  from  in- 
fection. 

2.  The  inflammatory  adhesion  has  the  tendency  to 
draw  the  lung  abscess  toward  the  surface,  thus  facili- 
tating approach  to  the  abscess.  The  rubber  coil  was 
placed  in  for  the  purpose  of  preventing  adhesions  of  the 
muscles  of  the  flap  to  the  cauterized  pleura,  and  thus  pre- 
serve a  clean  field  for  the  second  operation. 


148       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

After  this  procedure  a  second  radiograph  was  taken 
to  show  the  location  of  the  rubber  coil  in  its  relation  to 
the  lung  abscess.     It  was  shown  to  be  one  inch  lower 


Fig.   57.     Rubber  coil  showing  against  exposed  pleura,  demonstrating  relation 
to  lung  abscess. 


than  the  abscess,  and  therefore  served  as  a  valuable 
guide  in  the  second  operation.  (Fig.  57.)  Four  days 
after  the  first  operation  the  patient  was  again  anesthe- 
tized, the  wound  reopened,  the  rubber  coil  lifted  from  its 


EMPYEMA  AND  LUNCJ  ABSCESS. 


149 


bed,  and  the  clean  costal  pleura  exposed.  An  incision 
one  inch  in  length  was  made  in  the  upper  angle  of  the  ex- 
posed pleura,  and  then,  with  the  index  finger,  the  lung 
tissue  was  penetrated  and  the  abscess  wall  i  in  mediately 
felt.  A  blunt  forceps  was  then  pushed  into  the  abscess 
wall  and  widely  spread.  The  cavity  was  explored  with 
the  index  finger  and  found  to  consist  of  several  compart- 


Fig.  58.     Lung  abscess  cavity,  viewed  with  stereoscope,  will  show  four  bronchial 
openings. 


ments,  which  were  separated  by  friable  walls.  These 
walls  were  broken  up  and  two  calcareous  concretions  re- 
moved. There  was  no  hemorrhage.  The  procedure 
lasted  only  ten  minutes.  The  cavity  was  packed  with 
gauze  for  twenty-four  hours,  and  then  injected  with  33- 
percent  bismuth-vaselin  paste,  of  which  the  patient 
coughed  up  a  considerable  quantity  during  the  next  few 
hours.     Without  reinjection,  the  pus  secretion  from  the 


150       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

abscess  cavity  disappeared  within  ten  days,  and  only 
mucus  could  be  forced  out  by  intentional  coughing.  The 
depth  of  the  abscess  cavity  could  now  be  inspected  by 
ordinary  daylight,  four  bronchial  openings  being  plainly 


Fig.   59.      Multilocular  lung  abscess  injected  with  bismuth  paste. 


visible.  (Fig.  58.)  To  insure  the  closure  of  the  bron- 
chial openings,  their  mucous  lining  was  destroyed  with 
electric  cautery.  This  procedure  was  painless,  although 
the  resulting  smoke  passing  up  through  the  bronchi  and 
nostrils  was  irritating  and  disagreeable. 


EMPYEMA  AND  LUNG  ABSCESS. 


151 


The  cavity  is  now  rapidly  shrinking,  and  the  indica- 
tions for  permanent  closure  are  evident.  In  two  cases 
previously  treated  in  this  manner  the  cavities  closed  in 
from  two  to  four  weeks  after  the  operation. 

Fig.  59  illustrates  the  multilocular  condition  of  lung 
abscess  in  one  of  these  cases  treated  in  this  same  man- 


Fig.   59  A.     Diagrammatic  illustration  of  Fig.  59. 


ner.  While  this  procedure  is  comparatively  new,  and  to 
my  knowledge  has  not  as  yet  been  tried  by  others,  I  have 
employed  it  successfully  in  three  cases,  and  have  in  each 
instance  located  the  abscess  without  any  difficulty  and 
without  causing  a  hemorrhage,  and  therefore  anticipate 
that  the  method  will  be  tested  by  other  surgeons. 

The  task  of  definitely  locating  a  lung  abscess  has  al- 


152       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

ways  been  considered  rather  difficult,  and  many  an  opera- 
tion lias  had  to  be  abandoned  because  of  profuse  hemor- 
rhage in  searching  for  the  abscess.  With  the  aid  of  the 
stereoradiograph  and  the  subsequent  surgical  procedure 


Fig.   60.      Bronchial  tree  injected  with  bismuth  paste  for  anatomical  study. 


which  I  advocate,  the  locating  of  the  abscess  is  compara- 
tively easy  and  almost  certain,  and  the  danger  of  the 
operation  is  reduced  to  a  minimum. 
In  the  diagnosis  of  lung  abscesses  knowledge  of  the 


EMPYEMA  AND  LUNG  ABSCESS.  153 

anatomy  of  the  bronchial  tree  is  essential.  To  assist  in 
the  study  of  this  subject  I  have  produced  a  radiograph  of 
a  bronchial  tree  (Fig.  60)  which  I  believe  will  aid  in  the 
locating  of  abscesses. 

This  picture  was  produced  by  injecting  into  the  trachea 
of  a  fresh  cadaver  a  quantity  of  bismuth  paste  which 
penetrated  the  minutest  ramifications  of  the  bronchi,  in 
some  places  even  filling  the  alveoli  and  thus  producing 
the  cauliflower-like  shadows. 

The  division  of  the  trachea  takes  place  opposite  the 
sixth  dorsal  vertebra.  It  is  generally  assumed  that  the 
right  bronchus  is  a  continuation  of  the  trachea.  Prac- 
tically this  is  the  case,  but  our  radiograph  shows  that  the 
right  bronchus  deviates  17  degrees  and  the  left  40  de- 
grees from  the  axis  of  the  trachea.  The  number  of  sub- 
divisions in  the  bronchi  vary  from  six  to  ten,  those  in  the 
lower  lobe  having  more  subdivisions.  The  bronchioles 
appear  somewhat  beaded,  due  probably  to  overdistention 
by  the  paste.  This  picture  also  furnishes  the  true  rela- 
tions of  the  bronchi  to  other  structures  within  the  chest, 
as  they  actually  exist  in  life,  before  the  chest  cavity  is 
opened  and  the  lung  collapsed. 

I  trust  that  the  employment  of  the  stereoscopic  radio- 
graph and  the  anatomical  illustration  of  the  bronchial 
tree  will  add  much  to  our  diagnostic  ability,  and  that  the 
introduction  of  the  simple  and  effective  surgical  opera- 
tion here  described  will  aid  in  simplifying  the  surgery  of 
lung  abscess. 


CHAPTER  XII. 

BISMUTH  PASTE  IN  THE  CONSERVATIVE 
TREATMENT  OF  COLD  ABSCESSES. 

Surgeons  the  world  over  are  almost  unanimous  in  their 
opinion  that  cold  abscesses  should  neither  be  opened 
nor  drained,  but  they  have  not  yet  agreed  upon  a  method 
which  would  prevent  the  complications  and  dangers 
which  usually  follow  the  spontaneous  rupture  or  incision 
of  these  abscesses.  As  long  as  a  cold  abscess  is  closed,  it 
is  comparatively  harmless,  but  when  opened  it  immedi- 
ately becomes  a  source  of  danger.  Secondary  infection 
is  then  the  rule,  and  sepsis  and  death  the  frequent  conse- 
quences. Calot  says:  "To  open  a  spondylitic  abscess  or 
allow  it  to  open  spontaneously  means  to  open  the  gate 
through  which  death  nearly  always  enters.  A  physi- 
cian's viewpoint  in  the  treatment  of  cold  abscesses  is,  for 
the  life  of  the  patient,  of  the  utmost  importance." 

In  1858  Bouvier  said:  "It  is  common  to  see  both  adults 
and  children  in  whom  large  abscesses  cause  little  in- 
convenience, but,  when  these  abscesses  are  opened,  acute 
pain  and  extensive  inflammation  gradually  exhaust  and 
may  even  kill  the  patient." 

The  last  century  has  witnessed  many  changes  in  the 
treatment  of  cold  abscesses,  the  methods  in  each  period 
depending  upon  the  prevailing  opinions  which  were  held 
at  the  time  as  to  their  pathology. 

Before  Pasteur's  great  discovery,  when  surgeons  had 
no  conception  of  asepsis,  the  treatment  was,  of  course, 
irrational.  Dupuytren,  Larrey,  and  others  treated  cold 
abscesses  with  wide  incisions,  but  many  surgeons  were 

154 


COLD  ABSCESSES.  155 

decidedly  opposed  to  such  procedures.  The  mortality  at 
that  time,  according  to  Follin's  figures,  ranged  from  56  to 
70  percent  in  hip  diseases  and  spinal  caries.  In  the  light 
of  our  present  knowledge  of  the  disease  this  high  mortal- 
ity was  due  to  imperfect  immobilization,  bad  hygiene,  and 
the  lack  of  knowledge  regarding  the  necessity  of  steril- 
ization of  instruments  and  care  in  dressings. 

With  the  introduction  of  asepsis  and  the  modern  teach- 
ings on  tuberculosis  of  bones  and  joints  by  such  men  as 
Konig  and  Lannelongue,  the  treatment  was  radically 
changed.  It  was  shown  by  Lannelongue  that  the  cold 
abscess  was  the  result  of  a  primary  tuberculous  infection, 
and  consequently  he  advocated  the  early  radical  removal 
of  the  primary  focus.  This  certainly  was  rational  treat- 
ment. The  death  rate,  however,  from  shock  in  the  ex- 
tensive resections  of  hips  and  vertebrae  was  enormous, 
and  the  final  results  in  the  cases  which  survived  were 
deplorable  because  of  the  resulting  deformities. 

For  this  reason  this  method  soon  lost  its  popularity, 
and  a  reaction  to  less  radical  methods  took  place.  There- 
after the  treatment  was  limited  to  the  abscess,  and  the 
bony  lesions  from  which  it  sprang  were  ignored.  Cu- 
retment  of  the  abscess  lining  or  the  excision  of  the  ab- 
scess wall,  under  the  most  rigid  aseptic  precautions,  were 
practiced  apparently  with  favorable  results.  Wounds 
healed  by  primary  union,  and  patients  gained  rapidly  in 
health  soon  after  the  operations.  The  test  of  time,  how- 
ever, shattered  the  hopes  of  the  advocates  of  this  method, 
it  having  been  observed  that  the  cures  in  most  cases  were 
not  permanent.  The  reason  for  recurrences  with  this 
semiradical  method  is  apparent  when  the  following  facts 
are  considered: 

While  it  is  true  that  the  tuberculous  debris  within  an 
abscess  is  usuallv  sterile,  we  know  that  the  wall  itself  is 


156       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

the  seat  of  living  bacteria.  At  the  same  time  the  abscess 
wall  furnishes  the  fortification  against  the  spreading  of 
the  bacteria  into  neighboring  tissues.  Its  connective 
tissue  wall  forms  a  barrier  against  further  invasion. 
Would  it,  then,  be  rational  to  excise  or  scoop  out  these 
natural  barriers,  and  thereby  expose  large  surfaces  to 
the  implantation  of  the  living  bacteria,  which  were  com- 
paratively harmless  when  imbedded  in  the  connective 
tissue  of  the  abscess  wall?  Moreover,  by  removing  the 
lining  or  the  entire  abscess  wall  we  still  leave  the  primary 
lesion  intact,  which  still  retains  its  activity.  Of  what  ad- 
vantage, then,  is  the  excision  of  the  abscess  wall? 

Unless  the  primary  focus  is  already  extinguished,  or 
the  virulence  of  the  bacilli  so  much  attenuated  as  to  be 
harmless,  the  curetment  or  excision  of  the  abscess  wall 
can  be  of  little  avail. 

Practically  the  final  results  confirm  this  assertion. 
The  immediate  effects  in  many  of  the  operated  cases 
seem  excellent,  and,  no  doubt,  some  lasting  results  are 
obtained,  but  most  frequently  the  cavity  refills  with 
either  tuberculous  debris  or  purulent  secretion;  the 
wound  reopens,  and  frequently  secondary  infection  takes 
place.  If  the  process  is  not  so  violent  as  to  cause  death, 
the  condition  becomes  chronic  and  a  sinus  results. 

"While  this  semiradical  procedure  is  still  practiced  in 
some  countries,  it  has  been  largely  supplanted  by  the 
conservative  method. 

The  most  desirable  treatment  is  the  nonoperative  one. 
It  consists  in  allowing  the  abscess  to  become  absorbed. 
This  is  accomplished  by  complete  rest  in  bed,  immobili- 
zation, and  giving  the  patient  all  the  hygienic  advantages 
that  reinforce  the  natural  resistance  against  disease. 
The  conservative  orthopedic  surgeons  have  a  great  deal 
more  patience  with  these  cases  than  some  of  the  aggres- 


COLD  ABSCESSES.  157 

sive,  restless,  younger  generation  of  surgeons,  and,  no 
doubt,  have  saved  by  their  conservatism  thousands  of 
children;  but,  on  the  other  hand,  many  a  cripple  with  a 
discharging  sinus  hobbles  from  clinic  to  clinic  who  might 
have  been  spared  much  misery  if  his  abscess  had,  at  the 
proper  moment,  been  treated  by  proper  surgical  method 
instead  of  having  been  permitted  to  rupture  and  to  drain. 
The  most  effective  and  satisfactory  method  is  that  of 
aspiration  of  the  abscess  and  injecting  a  modifying  sub 
stance. 

Calot1  prescribes  the  following  rules  for  treating  cold 
abscess: 

1.  "It  is  forbidden  to  touch  abscesses  when  they  are 
not  easily  reached.  There  is  no  danger  that  these  will 
rupture  spontaneously. ' ' 

2.  "It  is  permitted  to  treat  abscesses  when  they  are 
easily  reached,  even  if  they  do  not  threaten  to  rupture 
spontaneously. ' ' 

3.  "It  is  our  urgent  duty  to  treat  abscesses  when  they 
threaten  to  rupture.  In  this  case  they  are  easily  access- 
ible. 'To  treat  them'  means  to  aspirate  and  then  inject 
some  substance  producing  a  healing  effect." 

I  subscribe  most  decidedly  to  rules  1  and  3,  but  can 
not  subscribe  to  rule  2,  as  it  is  my  belief  that  the  non- 
operative  treatment  should  be  persisted  in  as  long  as 
possible. 

As  long  as  the  patient  does  not  suffer  extreme  pain, 
and  has  very  little  fever,  he  should  be  given  a  chance  of 
cure  without  surgical  interference,  but  the  abscess  should 
be  constantly  watched,  and  as  soon  as  signs  of  threaten- 
ing rupture  appear  it  is  of  the  utmost  importance  that 
surgical  methods  be  employed.  If,  however,  there  ap- 
pear symptoms  of  pyrexia,  or  if  the  patient's  health  de- 


1  Calot:  Die  Behandlung  der  Tubereulosen  Wirbelsaulenentziindung. 


158       BISMUTH  PASTE  IX  CHRONIC  SUPPURATIONS. 

clines  steadily,  then  it  may  be  assumed  that  the  abscess 
contains  true  pus,  and  surgical  interference  is  not  only 
permissible,  but  is  urgently  required.  The  surgical  pro- 
cedure should,  however,  not  be  too  radical.  It  is  not  ju- 
dicious to  use  a  curet,  nor  is  irrigation  of  the  abscess  in- 
dicated. The  abscess  should  be  located,  aspirated,  and 
filled  with  a  modifying  substance. 

The  aspiration  and  injection  of  modifying  fluids  is,  at 
the  present  time,  the  most  popular  method  in  cases  in 
which  the  abscess  threatens  to  rupture.  Various  sub- 
stances have  been  used  at  different  periods  for  the  injec- 
tion of  these  cold  abscesses,  and  it  seems  that  nearly  all 
of  them  have  given  satisfactory  results.  Silver  nitrate, 
tincture  of  iodin,  alcohol,  corrosive  sublimate,  lactic  acid, 
ether  and  iodoform,  naphtolcamphor,  trypsin,  serums, 
guaiacol,  formalin,  and  many  others  have  been  used  at 
different  periods  of  the  development  of  this  curative 
method,  but  in  the  last  few  years  Calot's  mixture — 

01.  olivarum  50  grams 

Ether  sulf 50  grams 

Kreosot  2  grams 

Iodoform    5  grams 

— or  naphtolcamphor  (1  gram  in  5  grams  of  glycerin), 
and  lately  the  2-percent  formalin-glycerin  mixture  of 
Murphy,  have  been  most  in  favor. 

Some  surgeons  do  not  employ  modifying  fluids,  claim- 
ing good  results  with  simple  aspiration,  repeating  it  as 
often  as  the  abscess  refills.     (Gangolphe.) 

Simple  aspiration  may  be  compared  to  the  tappings  of 
pleural  exudates  in  tuberculous  pleurisy.  They  do  not 
often  cure  the  underlying  disease,  although  they  usually 
benefit  the  patient  temporarily.  The  aspiration  of  an 
abscess  is  an  incomplete  procedure,  since  it  can  not  re- 
move or  disinfect  the  original  focus  of  the  disease,  of 


(!(>U>  AllNOKKKKN. 


159 


which  the  abscess  is  only  a  consequence.  If  the  opening 
or  aspiration  of  the  abscess  meant  the  eradication  of  the 
disease,  the  problem  of  curing  spinal  tuberculosis  or  hip 
joint  disease  would  indeed  be  very  simple.  The  neces 
sity  of  frequent  repetition  of  the  aspiration,  furthermore, 
predisposes  to  secondary  infection,  which  is  practically 
avoided  by  using  modifying  substances. 


Fig.    61. 
rupture. 


Psoas  abscess,  pointing  in  the  lumbar  region.     Ready  for  spontaneous 


In  January,  1908,  I  tested  the  value  of  bismuth  paste 
as  a  modifying  substance  in  the  conservative  treatment 
of  cold  abscesses,  and,  finding  it  very  effective,  I  have 
since  employed  it  in  a  large  number  of  cases.  Now,  after 
two  years'  experience,  I  have  no  hesitation  in  recom- 
mending it  as  a  most  valuable  addition  to  other  modify- 
ing fluids. 


160       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

Method  of  Application. — A  cold  abscess,  when  it  lias 
reached  the  stage  of  spontaneous  rupture  (Fig.  61), 
should,  with  the  most  aseptic  measures,  be  opened  by  an 
incision  one-half  inch  in  length,  at  the  fluctuating  spot, 
and  the  contents  allowed  to  escape,  but  not  squeezed  out 
forcibly.  Vigorous  manipulation  is  harmful.  Then, 
through  this  small  incision,  a  quantity  of  not  more  than 
100  grams  of  a  10-percent  bismuth- vaselin  paste  is  in- 
jected into  the  cavity,  and  the  opening  is  not  sealed  or 
drained.  Gentle  massage  over  the  abscess  area  should 
then  be  made  in  order  to  spread  the  injected  paste  into 
all  the  folds  of  the  collapsed  abscess.  A  sterile  gauze 
dressing  is  placed  over  the  incision  and  a  five-yard 
sterile  gauze  bandage  is  snugly  put  on  and  securely 
pinned,  so  that  the  patient,  usually  a  child,  can  not  dis- 
place it  and  can  not  infect  the  wound.  This  method, 
properly  carried  out,  will  prevent  secondary  infection. 
The  gradual  contracting  of  the  cavity  forces  small  quan- 
tities of  the  thick  paste  from  within  through  the  small 
incision,  thereby  blocking  the  opening  and  preventing 
the  introduction  of  any  infectious  material.  Dressings 
are  to  be  changed  daily  under  the  most  scrupulous 
asepsis.  Should  the  fluid  reaccumulate,  the  incision  may 
be  reopened,  and  the  fluid  contents,  which  have  by  this 
time  become  serous,  allowed  to  escape,  but  the  injection 
need  not  be  repeated. 

The  first  trial  of  this  prophylactic  method  was  made  on 
January  17,  1908,  at  the  North  Chicago  Hospital  on  a 
two-and-one-half -year-old  boy,  who  had  a  tuberculous 
abscess  about  the  middle  of  his  tibia.  I  made  only  one 
injection,  and  the  abscess  was  obliterated  within  one 
week  and  remained  closed. 

This  favorable  result  encouraged  me  to  try  the  treat- 
ment in  the  following  case  of  psoas  abscess: 


(JO LI)  AHSOKSKKS. 


161 


A  boy,  aged  4%,  had  a  large  psoas  abscess  pointing  above  Poupart's 
ligament,  with  a  softened  area  at  its  summit.  A  quart  of  debris  was 
evacuated  and  the  cavity  injected  with  120  grams  of  a  10-percent  bis- 
muth-vaselin  paste.  The  temperature  remained  absolutely  normal  after 
this  injection,  whereas  previously  it  had  risen  from  99°  to  100°  every 


Fig.  62,     Abscess  of  trip  joint  injected  with  bismuth  paste  to  prevent  sinus. 


day.  The  incision  closed  in  four  days,  and  was  intentionally  reopened 
three  days  later  and  about  three  ounces  of  muddy,  but  sterile,  liquid 
were  removed,  and  60  grams  of  a  33-percent  bismuth-vaselin  paste  in- 
jected. The  opening  closed  three  days  later,  and  the  patient  gained 
rapidly  in  general  health. 


162       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

This  prophylactic  method  is  applicable  in  treating  cold 
abscesses  in  all  parts  of  the  body.  Several  cases  are 
here  cited  for  illustration : 


Pig.   63.     Normal  pelvis  of  same  age,  for  comparison  with  Fig.  62. 


Hip-joint  Abscess. — Master  E.  T.,  aged  7,  at  the  age  of  2%  years  fell 
and  soon  after  developed  an  abscess  in  his  hip.  One  year  later  his 
physician  incised  and  drained  the  abscess,  and  purulent  discharge  con- 
tinued for  two  years.  In  April,  1908,  I  made  the  first  injection  of 
bismuth  paste,  whereupon  the  sinus  closed.  With  the  aid  of  a  high 
shoe  the  boy  could  now  run  about  as  well  as  his  healthy  comrades, 
and  was  well  until  September,   1909    (sixteen   months  after  closure), 


COLD  ABSCKSSKS.  ]<)/> 

when  he  fell  downstairs,  which  accident  was  followed  by  chills  and 
fever  of  103°,  and  extreme  tenderness  of  the  hip.  For  three  weeks  his 
hip  was  treated  with  liniments,  etc.,  without  any  relief,  and  a  large 
abscess  in  the  gluteal  region  appeared.  In  this  condition  he  was  again 
brought  to  me  for  treatment.  On  October  24,  1909,  the  prophylactic 
method  of  bismuth  treatment  was  carried  out  as  follows: 

An  incision  two  inches  long  was  made  through  the  gluteal  muscles, 
reaching  a  deep  abscess.  The  pus  was  allowed  to  escape  without  any 
scooping  or  the  introduction  of  gauze,  and  the  resulting  cavity  was 


Fig.   64.      Patient  whose  pelvis   is  shown   in  Fig.   62,   standing  on   the  diseased 
limb  two  weeks  after  injection  of  abscess. 


filled  with  a  10-percent  bismuth  paste.  The  radiograph  (Fig.  62)  illus- 
trates the  size  and  shape  of  the  cavity.  The  shadow  of  a  buckshot 
represents  the  location  of  the  opening  of  the  sinus.  This  radiograph 
also  illustrates  the  extreme  tilting  of  the  pelvis  and  the  atrophy  of 
the  shaft  of  the  femur,  which  occurs  in  some  of  the  cases  of  hip  joint 
disease.  For  comparison  I  show  a  radiograph  (Fig.  63)  of  a  normal 
pelvis  of  a  child  of  the  same  age.  Child  has  fully  recovered  and  sup- 
ports his  body  weight  on  the  tuberculous  limb.     (Fig.  64.) 

Tuberculosis  of  Elbow  with    Multiple  Cold   Abscesses. — L.  R.,  aged 
18,  when  8  years  old  was  operated  upon  for  tuberculosis  of  the  knee 


164       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

joint.  Result,  primary  union,  with  considerable  shortening.  Since 
then  the  patient  remained  apparently  well  until  four  months  ago,  when 
a  swelling  in  his  left  elbow  began  to  form,  which  was  first  diagnosed 
as  rheumatism.  This  swelling  enlarged  and  the  elbow  became  entirely 
immovable.     Fluctuation   was   distinct   at  three   different  points.     The 


Fig.   65.      Tuberculous  elbow  joint  with  three  abscesses  before  injection  treatment. 


Fig.   66.     Reduction  in  size  of  arm  shown   in  Fig.   65   after  prophylactic,  con- 
servative treatment.     Secondary  infection  avoided. 


photograph  of  the  arm  (Pig.  65)  shows  the  size  of  the  swelling  before 
the  prophylactic  treatment  was  instituted.  March  1,  1910,  the  three 
abscesses  were  incised  at  their  softest  points,  and,  according  to  the 
method  described,  were  injected  with  bismuth  paste  No.  1,  this  33- 
percent  paste  being  employed  because  the  quantities  used  were  small. 
The  cloudy  discharge  changed  within  twenty-four  hours  to  a  clear 


COLD  ABS0E88E8. 


165 


straw-colored  fluid,  which  at  first  was  very  abundant,  but  gradually 
became  scanty.  The  opening  closed,  and  the  elbow  returned  to  its 
normal  size.  (Fig.  GO.)  Mobility  was  less  impaired  than  we  antici- 
pated. 

The  radiograph  (Fig.  67),  which  was  taken  after  the  abscesses  were 
injected,  shows  distinctly  the  size  of  each  abscess,  and  demonstrates 
the  fact  that  these  abscesses  did  not  communicate,  but  all  of  them 
had  their  origin  in  one  tuberculous  focus  in  the  external  condyle  of  the 
humerus. 

During  the  past  two  years  I  have  applied  this  method 
of  treating  cold  abscesses  in  nearly  all  parts  of  the  body, 
including  suppurating  lymph  glands  and  pararectal  ab- 
scesses, and  not  in  a  single  instance  have  I  experienced 
a  secondary  infection  and  high  fever.  I  have  not  trusted 
to  simple  aspiration,  and  have  employed  it  in  every  case 
of  cold  abscess  treated  during  the  past  two  years. 

Therapeutically  the  results  have  been  all  that  could  be 
desired;  in  fact,  of  twenty-six  cases  treated  in  this  man- 
ner in  only  one  did  a  sinus  persist,  and  in  this  case  a 
badly  diseased  hip  joint  was  responsible  for  its  failure  to 
close. 

This  method  has  already  been  tried  by  others.  Ridlon 
and  Blanchard  made  a  report  in  June,  1909,  to  the  Amer- 
ican Orthopedic  Association  of  eight  cases  treated  in  this 
manner  at  the  Home  for  Crippled  Children,  in  Chicago, 
in  which  institution  I  had  introduced  this  method  a  year 
previous  to  their  report.     Their  results  were  as  follows: 

Report  of  8  Cases  of  Cold  Abscess  Treated  by  Ridlon  and  Blaxchabd 
with  Bismuth  Paste. 


aj 

c3 
o 

0 

Name. 

Age, 
years. 

Disease. 

a 

0 

Is 

Abscess. 

Cured  in 

0 

3  ~ 

1 

Elmer  H. 

5 

Pott's  disease 

3% 

Psoas 

21  days 

9 

Samuel  J. 

7 

Hip  disease 

•> 

Thigh 

13  days 

3 

John  B. 

!i 

Hip  disease 

3 

Thigh 

14  days 

4 

Joseph  M. 

S 

Hip  disease 

2 

Thigh 

lrt  days 

5 

Josephine  0 

5 

Hip  disease 

2 

Thigh 

20  days 

6 

Hiram  W. 

17 

Pott's  disease 

1 

Lumbar 

17  days 

7 

Maggie  S. 

10 

Hip  disease 

2 

Thigh 

lii  days 

8 

George  T. 

9 

Hip  disease 

2 

Thigh 

15  days 

166       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

One  might  ask  why  surgeons  have  shifted  from  one  to 
another  of  these  modifying  substances  when  nearly  all  of 
them  have  fulfilled  their  purpose.     New  modifying  fluids 


Fig.   67.      Radiograph   showing  the  three   distinct  cavities  communicating   with 
the  elbow  joint.      (Case  shown  in  Fig.  65.) 


were  introduced,  not  because  the  older  ones  failed,  but, 
rather,  they  were  added  because  they  were  just  as  effec- 
tive and,  in  addition,  possessed  other  advantages,  such 
as  being  less  toxic,  less  irritating,  or  painless. 


COLD  ABSCESSES. 


167 


Action  of  Bismuth  Paste  as  a  Modifying  Substance. 

We  have  studied  the  effects  of  bismuth  paste  upon  the 
secretions  of  these  abscesses  by  cytologic  tests  in  several 
hundred  cases,  and  have  made  observations  which,  in  a 
large  measure,  explain  to  us  its  favorable  action  upon  the 
diseased  abscess  cavities  and  their  contents.     The  con- 


Openinc/ 
o/  Gbscess 

Three  dish'ncr 
abscesses,  nor 
commumcorwg 


Fig.    67  A.      Diagrammatic  illustration  of  Fig.   67. 


tents  of  tuberculous  abscesses  are  usually  sterile,  and 
consist  of  debris  with  a  very  few  white  blood  corpuscles. 
Within  twenty-four  hours  after  an  injection  of  the  bis- 
muth paste  the  fluid  will  contain  an  abundance  of  poly- 
morphonuclear leucocytes.  A  fibrinous  network,  in 
which  are  entangled  a  large  number  of  these  leucocytes 
and  some  red  corpuscles,  will  appear.     All  these  facts  in- 


168       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

dicate  that  there  is  an  inflammatory  reaction.  The  same 
cytologic  changes  have  been  noted  by  other  observers 
when  other  modifying  substances  have  been  applied. 

Coyon  and  Fiesenger  {Journal  des  Practiciens,  Octo- 
ber 20,  1909)  have  advanced  a  theory  which  places  the 
action  of  the  various  fluids  on  a  chemical  basis.  They 
have  shown  that,  in  the  more  acute  form  of  abscess,  there 
exists  a  proteolytic  ferment  analogous  to  the  tryptic  fer- 
ment of  the  pancreas,  which  coagulates  albumins  and 
changes  them  into  peptones  and  amido-acids.  This  fer- 
ment is  produced  by  the  destruction  of  the  polymorpho- 
nuclear leucocytes. 

In  contradistinction,  this  ferment  is  not  present  in 
tuberculous  abscesses  because  of  the  absence  of  the  poly- 
morphonuclear leucocytes  in  cold  abscess.  The  injection 
of  any  of  the  modifying  fluids  will  cause  the  appearance 
of  the  leucocytes. 

Soon  after  the  discovery  of  the  tubercle  bacillus  it  was 
believed  that  the  curative  action  of  modifying  injections 
was  due  purely  to  their  antiseptic  power,  but  it  was 
found  that  some  of  these  substances  exert  very  slight  bac- 
tericidal power  in  vitro,  while  within  an  abscess  their 
action  upon  bacteria  is  very  powerful.  Iodoform  is  a 
striking  example.  Its  retarding  action  upon  bacterial 
growth  outside  of  the  body  is  very  weak,  but  within  the 
living  tissues  it  exerts  a  marked  inhibition  upon  the 
growth  of  microorganisms,  especially  upon  that  of  tuber- 
cle bacillus. 

The  bactericidal  action  of  the  paste  does  not  depend 
upon  the  antiseptic  power  of  the  bismuth,  but  upon  an 
underlying  principle  which  governs  all  these  modifying 
substances — namely,  the  production  of  a  local  leucocy- 
tosis.  The  bismuth  has  a  chemotactic  action — it  attracts 
the  leucocytes  to  those  tissues  with  which  it  comes  in 


COLD  ABSCESSES.  169 

contact.     Indirectly,  then,  the  injection  of  the  paste  is  re- 
sponsible for  the  phagocytic  action. 

The  following  are  the  advantages  of  using  bismuth 
paste  instead  of  other  modifying  substances: 

1.  The  paste  is  injected  through  a  small  incision  in- 
stead of  using  a  trocar,  and  thus  the  possibility  of  miss- 
ing the  abscess  is  eliminated. 

2.  By  discarding  the  aspirating  needle  the  danger  of 
injuring  underlying  vital  organs  or  entering  blood  ves- 
sels is  avoided. 

3.  Through  an  incision  it  is  possible  to  evacuate  the 
larger  clumps  of  the  tuberculous  debris,  which  could  not 
pass  through  the  aspirating  needle. 

4.  The  thick  paste  within  the  cavity  will  allow  the 
escape  of  secretions  along  the  walls  of  the  abscess,  but 
will  not  permit  the  entrance  of  infectious  material;  thus 
secondary  infection  is  prevented. 

5.  Injections  of  other  modifying  fluids  must,  as  a  rule, 
be  repeated,  while  with  the  paste  the  first  injection  usu- 
ally attains  the  desired  result. 

6.  The  injection  of  bismuth  paste  is  not  painful  or 
irritating.  It  is  injected  in  a  warm,  semi-liquid  state, 
and  remains  long  enough  in  contact  with  the  diseased 
tissues  to  produce  its  therapeutic  effect.  The  vehicle 
(vaselin)  does  not  macerate  the  walls  of  the  abscess. 
Toxic  effects  from  bismuth  subnitrate  can  easily  be  pre- 
vented. 

7.  The  therapeutic  results  are  equal,  if  not  superior, 
to  those  obtained  by  other  modifying  substances. 

These  advantages  and  the  practical  results  obtained 
with  the  paste  in  treating  cold  abscesses  naturally  sug- 
gest the  question :  "Why  could  it  not  be  employed  for  the 
injection  of  tuberculous  joints  before  abscess  formation 
instead  of  iodoform  emulsion,  etc.?     This  question  has 


170       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

frequently  been  put  to  me.  I  have  been  reluctant  in  ad- 
vising it,  although.  I  have  employed  it  in  several  cases 
with  success,  but  I  encountered  one  failure  which  taught 
me  the  possibility  of  its  producing  harm.1 

In  the  past  few  months,  however,  I  have  renewed  its 
application  in  tuberculous  joints  by  a  modified  method, 
but  the  brief  period  which  has  elapsed  does  not  permit 
drawing  definite  conclusions  and  its  publication. 

I  do  not  as  yet  advise  the  general  use  of  the  paste  when 
abscess  is  not  formed;  at  least  not  until  the  reports  from 
large  clinics  have  established  the  safety  of  its  application 
and  its  advantage  over  the  methods  now  in  vogue. 


1  Beck:  Transactions  of  Sixth  International  Congress  on  Tuberculosis,  vol.  2. 


CHAPTER  XIII. 
LIMITATIONS  AND  CAUSES  OF  FAILURE. 

To  one  who  has  the  opportunity  of  treating  many  cases 
with  the  bismuth  paste,  new  possibilities  for  its  applica- 
tion constantly  suggest  themselves.  Its  application  in 
the  accessory  sinuses  of  the  nose  and  ear  is  so  extensive, 
and  its  possibilities  so  great,  that  a  special  chapter  is  de- 
voted to  their  consideration. 

In  dentistry  the  paste  has  likewise  found  a  place  of 
usefulness.  A  publication  by  Dr.  R.  Beck,  including  a 
collective  report  from  several  hundred  dentists  of 
America  and  Europe  who  have  made  use  of  it  in  pyorrhea 
alveolaris  and  sinuses  within  the  mouth,  indicates  that  in 
dentistry  there  are  also  great  possibilities  for  its  appli- 
cation.    A  special  chapter  is  written  on  this  feature. 

There  is  no  reason  why  the  same  beneficial  results  may 
not  be  obtained  in  lower  animals  affected  with  sinuses. 
In  this  branch  of  surgery  the  veterinaries  have  already 
taken  advantage  of  its  use.  In  the  American  Veterinary 
Review  (February,  1910)  Dr.  C.  A.  Leslie  published  a 
report  in  which  he  gave  histories  of  thirteen  cases  of 
various  forms  of  fistula?  in  horses  in  which  he  used 
bismuth  paste,  with  complete  recovery  in  every  case. 
Some  of  these  cases  had  been  operated  upon  as  many  as 
four  times  without  success,  and  with  this  simple  method 
a  complete  cure  was  obtained  within  ten  days.  Similar 
reports  not  yet  published  have  been  made  to  me  by  other 
veterinaries.  Should  these  reports  be  verified  in  veteri- 
nary colleges,  where  I  am  informed  this  method  is  being 

171 


172       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

tested,  this  treatment  will  certainly  prove  to  be  of  im- 
mense value. 

The  wide  range  of  application  of  bismuth  paste  must 
not,  however,  mislead  to  the  belief  that  there  are  no  limi- 
tations to  its  use.  There  are  suppurative  conditions  in 
which  it  is  of  no  benefit,  and  in  some  its  application  may 
even  be  harmful. 

First  of  all,  it  is  contraindicated  in  acute  inflammatory 
conditions,  such  as  acute  sinusitis,  acute  phlegmon, 
freshly  opened  acute  abscesses,  etc.  Although  some 
gratifying  results  have  been  reported  also  in  acute  con- 
ditions, we  have  been  conservative  in  its  application, 
having  occasionally  noted  an  aggravation  of  the  symp- 
toms after  its  use  in  acute  cases. 

For  obvious  reasons  it  should  never  be  injected  into 
a  fistula  of  the  gall-bladder  or  the  pancreas,  and  great 
care  should  be  exercised  when  making  injections  in  the 
vicinity  of  the  cranium,  where  there  is  a  possibility  of  the 
paste  finding  its  way  into  the  subdural  space,  as  it  would 
cause  a  compression  of  the  brain  similar  to  that  of  a 
blood  clot. 

A  hypodermic  needle  should  never  be  employed  to 
make  these  injections,  as  it  may  enter  a  vein,  and  thus 
the  paste  may  be  injected  into  the  circulation  and  cause 
death  by  blocking  the  branches  of  the  pulmonary  artery. 

Causes  of  Failure. 

"We  have  had  many  cases  referred  to  us  in  which  the 
method  had  been  applied  and  for  some  reason  the  desired 
results  had  not  been  obtained.  Thus  we  were  afforded 
a  good  opportunity  to  study  the  causes  of  failure  in  quite 
a  variety  of  most  interesting  cases.  The  citation  of  a 
few  examples  will  be  instructive  in  showing  the  causes 
of  failure. 


LIMITATIONS  AND  CAUSES  OK  FA  I  MIRK. 


173 


Foreign  Body. — W.  W.,  aged  4.  One  month  following  an  attack  of 
croup,  in  December,  1907,  became  suddenly  ill  with  chills  and  fever, 
and  pain  in  the  upper  arm.  Within  two  weeks  of  continued  intermit- 
tent rise  of  temperature,  up  to  104.5°,  a  swelling  midway  between  the 
shoulder  and  elbow  appeared.  Diagnosis:  osteomyelitis.  A  half  pint 
of  pus  was  evacuated  through  three  incisions  from  shoulder  to  elbow. 
The  suppuration  failed  to  cease  within  a  reasonable  time,  and  another 
operation  was  performed,  in  which  a  considerable  amount  of  necrosed 


Pig.  68. 


69. 


Figs.  68,  69.  Tip  of  probe  (Fig.  6S,  F)  within  the  shaft  of  humerus  as  a  cause 
of  failure  of  bismuth  injections.  Cavity  filled  with  bismuth  paste  (Fig.  69)  after 
removal  of  foreign  body. 


bone  was  removed  and  the  entire  length  of  the  medullary  shaft  of  the 
humerus  was  curetted.  Five  weeks  later  the  discharge  still  persisted. 
At  this  time  the  bismuth  paste  treatment  was  tried  by  the  physician 
in  charge,  but  with  no  benefit.  Therefore  another  radical  operation 
was  undertaken  and  more  necrosed  bone  removed.  Bismuth  paste 
was  again  injected,  and  after  a  sufficient  trial  it  was  discontinued. 
In  July,  1908,  the  boy  was  brought  to  Chicago  for  the  bismuth  treat- 
ment. The  radiographs  here  shown  (Figs.  68,  69)  explain  the  cause 
of  failure.     The   tip  of  a  probe,   one  and   one-half   inches   long,   was 


174       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

lodged  in  the  shaft  of  the  humerus.  After  its  removal  the  bismuth 
paste  was  injected  and  all  sinuses  promptly  closed  without  a  recur- 
rence. 

Foreign  Body. — J.  N.,  aged  14.  Developed  an  osteomyelitis  in  the 
upper  part  of  the  humerus  and  the  tibia  four  years  ago.  After  the 
usual  treatment  at  home,  which  included  curettage  and  drainage  of 
the  bone  cavities,  there  appeared  to  be  no  tendency  to  healing.  The 
sinuses  continued  to  discharge  pus  profusely.  He  was  then  brought 
to  hie  for  the  bismuth  treatment. 

A  radiograph  of  the  humerus,  taken  before  the  injection  of  bis- 
muth paste,  shows  a  shadow  resembling  a  sequestrum.  In  the  pres- 
ence of  a  sequestrum  the  paste  would  be -of  no  avail,  and  I  therefore 
proposed  a  thorough  curettage  before  injection.  During  the  operation 
I  noticed  a  dark  striated  object  lying  within  the  shaft  of  the  humerus. 
It  was  resilient,  like  a  large  blood  vessel,  and  upon  extraction  proved 
to  be  a  piece  of  rubber  tubing  two  and  one-half  inches  long.  Bis- 
muth paste  would,  no  doubt,  have  been  a  failure  had  we  not  discovered 
the  foreign  body  beforehand. 

These  two  cases,  however,  represent  accidents,  and  can 
not  be  taken  as  examples  of  frequent  causes  of  failure; 
but  the  disease  itself  very  often  leaves  a  foreign  body  at 
the  seat  of  trouble — namely,  the  sequestrum. 

Sequestra  are  the  most  frequent  causes  of  failure. 
Their  diagnosis  has  been  extensively  studied  by  my 
brother,  Dr.  Carl  Beck,  who  satisfied  the  members  of  the 
Surgical  Society  of  Chicago  that  sequestra,  when  present, 
can  be  recognized  by  means  of  radiographs  practically 
in  all  cases.1  When  a  sequestrum  is  present  we  do  not 
expect  a  cure  until  it  has  been  removed.  Nevertheless,  a 
risky  operation  should  be  undertaken  only  as  a  last  re- 
sort. I  know  of  two  instances  in  which  sequestra  have 
healed  in  during  the  bismuth  treatment. 

Large  Sequestrum  of  Ulna. — L.  B.,  aged  12,  with  congenital  syphilis, 
was  treated  by  me  for  this  condition  the  first  three  years  of  his  life. 
For  seven  years  thereafter  he  enjoyed  comparatively  good  health  and 
normal  growth.  At  the  age  of  10  he  developed  a  remittent  fever, 
which  lasted  six  months,  and  debilitated  the  boy  very  much.  With 
antiluetic    treatment   he    gradually    recuperated   until    he   reached    his 


1  Carl  Beck,   Chicago:  Chronic  Osteomyelitis— Diagnosis  and   Treatment. — 
Surgery,  Gynecology  and  Obstetrics,  February,   1910. 


LIMITATIONS  AN))  CAUSES  OF  FAILURE.  175 

11th  year.  Thereafter  he  was  sickly  i'or  one  year,  and  returned  for 
treatment  at  the  age  of  12.  He  had  a  daily  temperature  of  from  LOO  to 
103°,  was  extremely  anemic  and  emaciated.  His  legs  helow  the  knees 
and  his  forearms  were  very  much  enlarged.  Radiographs  of  these 
parts  were  taken,  and  it  was  found  that  suppurative  osteitis  had  taken 
place  in  practically  all  of  the  bones  of  these  parts,  showing  softened 
areas  on  the  skin,  which  indicated  the  presence  of  abscesses.  On  the 
right  forearm  was  a  sinus,  through  the  opening  of  which  a  portion  of 


Fig.   70.      Sequestrum  of  the  ulna,  requiring  removal  before  bismuth  injection. 

dead  bone  protruded.  The  radiograph  (Fig.  70)  of  this  arm  shows 
enormous  destruction  of  the  ulna  and  elbow  joint.  The  entire  ulna 
was  practically  a  sequestrum,  and  the  futility  of  any  conservative 
treatment  was  evident.  The  sequestrum  was  removed  under  anes- 
thesia, and  its  natural  size  and  colors  are  shown  in  the  colored  plate. 
The  cavity  was  packed  with  gauze,  and  the  next  day  was  filled  with  bis- 
muth paste.  The  abscesses  on  the  left  arm  were  incised  and  injected, 
and  closed  without  secondary  infection  within  three  days.    Temperature 


176       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

ceased  after  first  injection.  The  healing  progressed  rapidly,  and  three 
weeks  after  the  operation  the  wound  was  practically  closed,  the  boy 
had  gained  twelve  pounds,  and  had  practically  normal  motion  in  both 
arms.  (Fig.  71.)  It  must,  however,  be  stated  that  he  had  at  the  same 
time  received  antiluetic  treatment,  which  may,  to  a  certain  degree, 
account  for  the  rapid  improvement,  although  the  same  treatment  be- 
fore the  operation  did  not  have  this  effect. 


Fig.   71.     Complete  closure  three  weeks  after  operation  and  bismuth  treatment. 
Removal  of  ulna  from  left  arm. 


Faulty  Technic. 

Faulty  technic  is,  no  doubt,  the  cause  of  many  fail- 
ures. I  have  often  been  surprised  to  find  that  cases  re- 
ferred to  me,  in  which  the  paste  had  been  used  "faith- 
fully" for  months  without  success,  responded  to  my  first 
injection  and  closed. 

The  underlying  principle  must  always  be  kept  in  mind 
that  the  bismuth  paste  must  be  soft  enough  to  permit  its 
flowing  into  the  remotest  parts  of  the  channels  and  filling 
every  one  of  them  completely.    In  Fig.  72  we  show  a 


LIMITATION'S  AND  CAUSES  OF  FAILURE.  177 

bone  cavity  which  was  injected,  but  not  filled  completely. 
If  a  small  side-pocket  or  branch  of  a  sinus  is  missed,  the 
suppuration  will  continue  and  in  time  the  entire  tract  of 
the  sinus  become  reinfected. 


Fig.  72.  Incomplete  injection  of  abscess  cavity,  demonstrating  cause  of  failure 
of  bismuth  treatment. 

Unexplained  Causes  of  Failure. 

Empyema;  Estlander  Operation;  Closure  with  Paste. — Miss  L.  E., 
aged  28.  Her  family  and  personal  history  are  negative  as  to  tuber- 
culosis. Four  years  ago  she  developed  an  acute  pleurisy,  with  effu- 
sion. Two  weeks  later  purulent  fluid  was  aspirated,  whereupon  a 
resection  of  one  rib  was  performed  and  drainage  instituted.  For 
eighteen  months  a  copious,  purulent  discharge  persisted.  A  second 
operation  was  performed  for  the  purpose  of  establishing  a  counter- 
drainage,  but  this  also  failed   to  stop  suppuration.     As   a  last  resort 


178       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

an  extensive  Estlander  operation  was  performed,  but  even  this  radical 
procedure  did-  not  suffice  to  stop  the  discharge.  The  bismuth  injec- 
tions were  then  tried  at  home,  and,  while  the  discharge  became  more 
scanty  and  less  purulent,  it  did  not  cease.  Retention,  with  fever, 
often  occurred.     With  this  history  the  patient  arrived  at  our  hospital 


Fig.  73.     Injection  of  empyema  after  Estlander  operation  has  failed  to  obliter- 
ate the  cavity. 


in  October,  1909.  The  radiograph  here  shown  (Fig.  73)  gives  a  vivid 
illustration  of  the  true  condition  within  the  chest  which  existed  after 
an  Estlander  operation.  The  paste  occupies  the  remaining  cavity. 
The  upper  part  of  the  lung  is  perfect  and  functionating. 

The  paste,  which  was  in  the  chest  cavity,  was  washed  out  with 


LIMITATIONS  AND  CAUSES  OF  FAILURE.  179 

warm  olive  oil,  and  the  following  day  a  fresh  injection  of  bismuth 
paste  No.  1  was  made.  The  secretion  became  sterile,  and  the  sinus 
closed  within  one  week  and  has  remained  so  to  date.  There  has  been 
no  elevation  of  temperature  or  discomfort,  and  a  radiograph  taken  re- 
cently shows  the  absorption  of  the  paste  and  the  distention  of  the 
lung.  These  are  signs  most  promising  for  the  permanency  of  the 
cure,  although  recurrence  is  possible. 

We  have  noticed  that  there  are  two  classes  of  cases — 
one  class  responds  promptly  to  the  bismuth  treatment, 
while  the  other  is  very  refractory.  To  which  class  a  case 
belongs  is  usually  decided  after  the  first  injection.  If 
the  purulent  discharge  changes  into  a  serous  one,  a  good 
result  is  to  be  anticipated,  and  a  closure  usually  follows 
the  first  injection.  If  the  discharge  remains  purulent, 
the  outlook  is  not  so  promising.  The  injection  is  not, 
however,  repeated  for  at  least  one  week.  Only  the  daily 
dressings,  with  frequent  microscopical  examinations,  are 
continued.  Thereafter  the  sinus  is  reinjected  every  three 
or  four  days  for  a  reasonable  length  of  time — about  a 
month.  If  no  improvement  is  noticed,  the  cause  of  fail- 
ure must  be  searched  for,  which  in  some  cases  remains 
inexplicable. 

The  limitations  here  prescribed  may  seem  too  strict 
and  unnecessarily  conservative  to  surgeons  who  have 
already  tried  the  bismuth  paste  and  obtained  good  results 
even  in  cases  where  I  do  not  recommend  its  use.  Never- 
theless, I  insist  that  it  is  far  safer  for  the  present  to  limit 
its  use  to  such  cases  where  our  experience  has  assured  us 
of  its  safety  and  usefulness. 


CHAPTER  XIV. 

BISMUTH  POISONING  AND  ITS  PREVENTION. 

The  introduction  of  new  remedies  is  usually  met  with 
skepticism,  and  the  failures  and  possible  dangers  are 
pointed  out  first.  This  is,  of  course,  most  desirable,  since 
it  helps  to  eliminate  the  objectionable  features  from 
otherwise  useful  methods.  The  x-ray  received  its  first 
blow  when  the  reports  of  x-ray  burns  began  to  pour  into 
the  literature,  but  after  fourteen  years  of  its  employment, 
when  its  use  has  been  increased  a  hundredfold,  reports 
of  burns  are  comparatively  rare. 

Vaccination,  antitoxins,  and  anesthetics  passed  through 
similar  experiences  until  their  true  value  was  recognized. 
There  is  no  remedy  of  any  importance  which  has  not 
some  objectionable  feature,  and  its  true  value  depends 
only  upon  the  relative  amount  of  good  to  be  accom- 
plished by  it.  Chloroform  may  cause  death,  but  never- 
theless thousands  of  persons  request  anesthetics,  know- 
ing their  usefulness. 

Bismuth  paste  is  no  exception  to  the  rule,  and  its 
objectionable  features  were  brought  forward  shortly 
after  the  appearance  of  my  first  article  on  the  subject. 
The  objection  advanced  is  the  toxic  effect  following  its 
administration.  It  is  far  safer  to  magnify  this  danger 
than  to  make  too  light  of  it,  but  an  undue  exaggeration 
of  this  complication  may  deter  many  from  applying 
an  otherwise  useful  method  of  treatment.  Neither  my 
brothers  nor  I  have  had  a  single  case  of  poisoning  in  our 
experience  with  several  hundred  cases.    I  have,  neverthe- 

180 


BISMUTH  POISONING.  181 

less,  at  every  opportunity  warned  the  profession  againsl 
this  possible  danger. 

It  must  be  admitted  that  in  the  application  of  bismuth 
paste  toxic  effects  may  be  produced.  The  slow  absorp- 
tion of  the  metallic  bismuth  from  cavities  where  large 
quantities  are  retained  for  a  long  period  causes  symptoms 
of  poisoning  similar  to  those  of  mercurial  intoxication. 

The  first  symptom,  a  slight  lividity  of  the  skin,  ap- 
pears during  the  second  or  third  week.  Later  we  find 
small  blue  ulcerations  of  the  gums  and  back  of  the  wis- 
dom teeth,  and  a  black  discoloration  underneath  the 
tongue.  Soon  thereafter  patient  complains  of  nausea, 
headache,  and,  frequently,  diarrhea.  The  urine  contains 
epithelial  casts  and  some  albumin.  If  the  progress  is  not 
checked,  the  ulcerations  will  enlarge,  the  teeth  become 
loose,  and  the  patient  become  cyanotic  and  begin  to  lose 
considerably  in  weight,  and  finally  may  succumb  to  the 
effects  of  poisoning. 

Administration  of  bismuth  subnitrate  in  overdoses 
may  produce  two  distinct  varieties  of  poisoning: 

1.  The  acute  nitrite  poisoning",  which  results  from  the 
rapid  absorption  of  large  quantities  of  nitrites  liberated 
in  the  intestines  from  the  bismuth  subnitrate. 

2.  The  slow  but  constant  absorption  of  the  metallic 
bismuth  from  either  the  intestinal  tract  or  the  serous  cav- 
ities, or  when  injected  into  wounds — bismuth  poisoning". 

The  instances  of  toxic  effects  from  the  use  of  bismuth 
subnitrate  in  medicine  and  surgery  have  been  so  rare 
that,  until  recently,  physicians  have  regarded  its  adminis- 
tration as  perfectly  harmless.  Schuler1  and  Von  Barde- 
leben2  have  pronounced  its  action  as  nontoxic,  the  latter 


1  Schuler:  Zeitschrift  fur  Chirurgie.   1885. 

2  Von   Bardeleben:  Deutsche  Medizinische   Wochenschrift,    1901.    No. 
544. 


182       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

having  treated  one  hundred  cases  of  extensive  burns  by 
dusting  with  bismuth  subnitrate,  and  observed  no  un- 
pleasant symptoms  therefrom.  Professor  Miihlig1  ad- 
ministered 20  grams  daily  for  a  prolonged  period  with- 
out producing  any  poisonous  effect. 

It  was,  therefore,  not  surprising,  when  radiographers 
began  to  use  bismuth  subnitrate  for  the  purpose  of 
obtaining  radiographs  of  the  stomach  and  intestines,  that 
they  had  no  hesitancy  in  administering  large  doses,  and 
boasted  of  the  safety  with  which  as  much  as  40  grams  in 
one  dose  could  be  administered.  The  subject  of  bismuth 
poisoning  has  been  revived  only  within  the  past  three 
years,  during  which  time  radiographers  have  employed 
the  drug  more  extensively. 

Bismuth  Poisoning-  Due  to  Dusting"  Powder. 

The  first  authentic  report  of  bismuth  poisoning  was 
made  by  Theodor  Kocher2  in  1882,  who  observed  that  the 
insoluble  bismuth  preparation,  when  applied  to  large 
wound  surfaces,  is  capable  of  yielding  enough  bismuth 
to  absorption  to  produce  poisonous  effects.  Similar  cases 
were  reported  by  Professor  Peterson.3  Thereafter  the 
literature  on  the  subject  remained  silent  until  1901,  when 
Professor  Miihlig4  reported  the  following  two  cases: 

Case  1.  A  man,  aged  26,  received  burns  on  both  arms,  hand,  and 
neck,  which  were  dressed  with  oil  for  three  days  and  the  pure  bismuth 
subnitrate  applied.  Two  weeks  later  a  black  border  around  the  teeth 
appeared,  and  within  five  more  days  the  whole  mouth  and  uvula  were 
grayish-blue  and  slightly  ulcerated.  Urine  remained  normal;  diges- 
tion normal.  Recovery  took  place  after  wounds  were  curetted  and 
freed  from  bismuth. 

Case  2.  A  man,  aged  34,  was  burned  on  both  legs.  Treatment  the 
same  as  in  case  1.  Twelve  days  after  first  bismuth  dressing  symp- 
toms identical   with   those   in  case  1   appeared.     Urine   and   stool   re- 


1  Miihlig:  Munchener  Medizinische  Wochenschrift,   1901,  No.  13,  p.  592. 

3  Kocher:  Volkmann's  Klinische  Vortrage,  1882,  p.  224. 

3  Peterson:  Deutsche  Medizinische  Wochenschrift,  June  20,  1883. 

*  Miihlig:  Munchener  Medizinische  Wochenschrift,   1901,  No.  13,  p.  592. 


BISMUTH  POISONING.  183 

mained  normal.  The  curettage  of  the  wounds  resulted  in  prompt  re- 
mission of  the  symptoms.  The  bismuth  used  in  these  cases  was  free 
from  impurities. 

A  similar  case  was  reported  by  Dressman:1 

Case  3.  A  man,  aged  30,  received  a  burn  of  third  degree.  Five 
days  later  a  10-percent  bismuth  salve  was  applied.  Three  weeks  later 
a  black  sediment  was  discovered  in  the  urine.  A  severe  stomatitis, 
with  deglutition  pains,  followed.  A  bluish-green  border  around  his 
teeth  was  noticed,  and  the  mouth  resembled  the  condition  which  exists 
after  eating  huckleberries.  After  the  bismuth  dressings  were  stopped 
the  symptoms  abated,  but  even  six  months  later  there  were  marks 
around  the  teeth. 

These  cases  prove  that  absorption  of  bismuth  sub- 
nitrate,  when  applied  as  dusting  powder  on  burns,  may 
produce  symptoms  of  bismuth  poisoning,  which,  how- 
ever, subside  as  soon  as  the  bismuth  is  removed.  None 
of  these  cases  were  fatal. 

Nitrite  Poisoning  Due  to  Bismuth  Subnitrate. 

The  first  fatal  case  directly  traceable  to  the  adminis- 
tration of  bismuth  subnitrate  for  diagnostic  purposes  is 
reported  by  Bennecke  and  Hoffman:2 

Case  4.  A  baby,  aged  3  weeks,  suffering  from  enteritis,  weak  and 
emaciated.  A  mixture  of  three  grams  of  bismuth  subnitrate  in  100 
cubic  centimeters  of  buttermilk  was  administered  by  stomach  in  order 
to  diagnosticate  a  pyloric  stenosis  by  rontgenograph.  Twelve  hours 
afterward  cyanosis  developed,  collapse  followed,  and  the  child  died 
three  hours  later.  Post-mortem  examination  revealed  bismuth  in  the 
bowel,  and  small  quantities  in  the  liver  and  blood.  Methemoglobine- 
mia was  present. 

From  the  same  clinic  a  similar  case  was  reported  by 
Bohme.3 

Case  5.  A  child,  aged  iy2,  markedly  rachitic,  artificially  fed.  and 
marasmic,  received  a  few  grams  of  bismuth  subnitrate  by  stomach  for 


1  Dressman:  Miinchener  Medizinische  Wochenschrift.  1901.  No.  6.  p.  23S. 

3  Bennecke  and  Hoffman:  Miinchener  Medizinische  Wochenschrift.  1906, 
No.  19. 

3  Bohme:  Archives  fiir  Experimentelle  Pathologie  und  Pharmakologie.  p. 
441,   1907. 


184       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

radiographic  purpose.  Stomach  was  washed  out,  and  no  symptoms  of 
poisoning  appeared.  Two  days  later  a  few  grams  of  bismuth  subnitrate 
were  injected  by  rectum  for  the  same  purpose,  and  again  the  bismuth 
was  washed  out.  Three  hours  later  the  child  was  suddenly  seized  with 
pain,  became  cyanotic,  pale,  skin  cool,  pulse  small;  it  died  in  thirty 
minutes. 

Section.  Distinct  methemoglobinemia,  all  mucous  membranes  were 
brownish  discolored,  marked  rachitis,  dilatation  of  the  stomach,  with 
stenosis  of  pylorus.  Colon  contained  large  quantities  of  black  and 
white  bismuth. 

Professor  Hefter  suggested  that  death  might  have 
been  caused  by  nitrite  poisoning.  The  blood  and  peri- 
cardial fluids  were  tested,  and  in  both  nitrites  were 
found.  Bismuth  could  not  be  detected  in  the  liver  or 
blood.  These  chemical  findings  threw  new  light  on  both 
cases,  and  prompted  Dr.  Bohme  to  determine  the  true 
cause  of  bismuth  subnitrate  poisoning.  The  results  of 
his  experiments  were  as  follows: 

A  number  of  pure  cultures  of  the  bacterium  coli  were 
found  to  liberate  nitrites  in  every  case  when  added  to 
bouillon  to  which  some  bismuth  subnitrate  had  been 
added.  The  controls  of  bouillon — treated  the  same  way, 
but  without  the  addition  of  bismuth — remained  free  from 
nitrites.  This  experiment  was  repeated  by  using  a  solu- 
tion of  children's  stool  instead  of  pure  cultures,  and  in 
every  instance  the  formation  of  nitrites  was  marked, 
while  the  same  experiments  with  stools  from  grown  per- 
sons showed  nitrites  absent  in  40  percent,  slight  in  35 
percent,  and  marked  in  only  25  percent  of  the  cases. 
The  character  of  food  seemed  not  to  influence  the  nitrite 
formation,  as  some  of  the  adults  received  a  milk  diet. 

The  next  question  Bohme  determined  was  whether  the 
formation  of  nitrites  would  occur  in  feeding  lower  ani- 
mals with  bismuth  subnitrate.  Cats  and  rabbits  were 
used  for  experiments,  and,  after  finding  their  stools  and 
urine  free  from  nitric  acid,  they  were  given  from  three  to 


BISMUTH  POISONING.  185 

five  grams  of  bismuth  subnitrate  in  milk.  Nitrates  ap- 
peared in  the  urine  after  a  few  hours,  and  did  not  cease 
to  be  eliminated  from  the  kidney  for  twenty-four  hours. 
Reaction  to  nitrites  was  absent  in  the  rabbits  and  only 
faintly  marked  in  the  cats. 

To  prove  that  children's  feces  mixed  with  bismuth 
subnitrate  would  liberate  nitrites  in  the  bowel  of  the  rab- 
bit, Bohme  injected  a  mixture  of  five  grams  of  each  into 
a  part  of  the  bowel  by  first  ligating  the  loop.  Nitrates 
and  nitrites  were  found  in  the  urine,  but  not  in  the  blood 
taken  from  the  hearts  of  the  animals.  In  the  feces  of  the 
ligated  part  of  the  bowel  a  large  quantity  of  nitrates  and 
nitrites  was  found.  In  trying  larger  quantities  by  the 
same  method,  and  testing  the  urine  hourly,  the  quantity 
of  nitrates  and  nitrites  increased,  but  not  enough  was 
absorbed  to  cause  methemoglobinemia. 

By  these  experiments  Bohme  proved  by  test  tube  and 
animal  experiments  that  the  feces  of  children,  when  in 
contact  with  bismuth  subnitrate,  will  liberate  nitrites, 
which  are  quickly  absorbed  from  the  intestines  and  found 
in  the  urine.  While  methemoglobinemia  was  not  pro- 
duced by  the  absorption,  it  must  be  assumed  that  the  ab- 
sorption of  larger  quantities  would  produce  methemo- 
globinemia.    Experiments  proved  this  to  be  a  fact. 

Collishon1  reports  two  cases  of  accidental  nitrite  poi- 
soning in  which  sodium  nitrite  instead  of  the  sodium  ni- 
trate was  given.  The  symptoms  were  cyanosis,  extreme 
weakness,  and  a  grayish-blue  discoloration  of  the  mucous 
membrane  and  the  tongue;  they  were  so  severe  as  to  pro- 
duce collapse,  but  cleared  up  after  the  drug  was  discon- 
tinued. 

Routenberg2  reported  a  case  in  which  a  methemoglobin- 


1  Collishon:  Deutsche  Medizinische  Wochenschrift,  1SS9.  No.  41. 

2  Routenberg:  Berliner  Klinische  Wochenschrift.  1906.  No.  43,  p.  1397. 


186       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

emia,  with  the  usual  symptoms  of  nitrite  poisoning,  fol- 
lowed the  rectal  injection  of  50  grams  of  bismuth  sub- 
nitrate  in  400  cubic  centimeters  of  oil  of  sesame,  and, 
while  the  author  ascribes  the  poisoning  to  the  contami- 
nation of  the  oil,  the  analogy  to  other  similar  cases  leads 
one  to  suspect  that  it  was  a  case  of  nitrite  poisoning. 

A  recent  report  of  fatal  nitrite  poisoning  due  to  bis- 
muth subnitrate  is  published  by  Novak  and  Giitig.1 

Case  6.  A  man,  aged  44,  who,  a  year  after  a  retrocolic  gastro- 
enterostomy, suffered  from  symptoms  of  obstruction,  received  in  July, 
1908,  a  rectal  injection  of  four  tablespoonfuls  of  bismuth  subnitrate 
suspended  in  two  liters  of  water,  to  test  the  function  of  the  anas- 
tomosis. Soon  after  the  x-ray  examination  the  bowels  were  washed 
out.  He  had  a  restless  night.  In  the  morning  the  nurse  noticed  a 
discoloration  of  the  patient's  skin.  Gradually  the  patient  became 
grayish-green,  mucous  membranes  cyanotic,  temperature  40°  C,  pulse 
96,  had  stertorous  breathing,  and  did  not  respond  to  treatment.  Vene- 
section revealed  the  blood  to  be  of  a  chocolate  color,  due  to  methemo- 
globinemia. Patient  died  eighteen  hours  after  rectal  injection  of  bis- 
muth subnitrate.  Spectroscopic  examination  of  the  blood  a  few  hours 
after  death  showed  that  it  had  returned  to  normal,  the  brown  color 
having  changed  to  red.  Two  days  later  the  post-mortem  examination 
proved  that  the  methemoglobinemia,  which  was  positive  before  death, 
had  now  disappeared  and  blood  had  assumed  a  normal  color. 

This  case  also  gave  further  impetus  to  investigation. 
"The  administration  of  100  grams  of  bismuth  subnitrate 
by  mouth,  then  by  rectum,  and  through  a  fistula  into  the 
small  and  large  bowels  of  dogs  and  rabbits,  failed  to  pro- 
duce any  symptoms  of  poisoning,  while  in  cats  much 
smaller  quantities  (20  grams)  would  cause  death  in  ten 
hours.  Seven  hours  after  ingestion  of  this  quantity  the 
-cat  vomited,  her  mucous  membranes  became  bluish-gray, 
blood  assumed  a  chocolate  color,  and  spectroscopic  ex- 
amination revealed  the  methemoglobin  stripe  in  the 
red." 

This   proves  that   certain   animals   are   susceptible   to 


1  Novak  und  Giitig:  Berliner  Klinische  Wochenschrift,  1908,  No.  39,  p.  1764. 


BISMUTH  POISONING.  187 

nitrite  poisoning,  while  others  are  not.  It  is  not  yet 
fully  determined  to  which  class  the  human  belongs. 

Maasen  proved  that  certain  bacteria  in  the  bowel  con- 
vert the  nitrites  into  ammonia  or  into  nitrogen.  It  is 
likely  that  the  bismuth  subnitrate  ingested  always  causes 
a  liberation  of  small  quantities  of  nitrites,  which  are 
either  absorbed  (and  owing  to  the  small  amount  cause  no 
toxic  symptoms)  or  are  changed  in  the  intestine  into  am- 
monia or  nitrogen. 

When,  however,  large  quantities  of  bismuth  subnitrate 
are  given,  and  the  liberation  of  nitrites  is  abundant  and 
can  not  be  neutralized  quickly,  typical  symptoms  of  ni- 
trite poisoning  will  appear.  Alcohol  and  glycerin  accele- 
rate the  formation  of  nitrites  in  the  intestines.  This  sug- 
gests to  us  a  practical  point — namely,  when  we  encounter 
a  case  of  nitrite  poisoning,  to  withhold  alcoholics  and 
glycerin  from  ingestion  and  administer  some  form  of 
iodin. 

From  these  experiments  and  reports  of  fatal  cases  Ave 
must  conclude  that  the  poisonous  effects  of  the  bismuth 
subnitrate  were  not  due  to  the  absorption  of  the  metallic 
bismuth,  but  to  the  absorption  of  nitrites,  which  caused 
the  methemoglobinemia.  This  methemoglobinemia  is 
the  factor  producing  most  of  the  clinical  symptoms — the 
cyanosis,  dyspnea,  diarrhea,  and  cramps.  The  sudden 
change  in  the  blood  impairs  the  internal  or  tissue  respi- 
ration, and  the  patient  succumbs,  with  symptoms  of  suf- 
focation. 

It  appears  that  the  intestine,  and  especially  the  sig- 
moid and  the  rectum,  are  the  laboratories  for  the  libera- 
tion of  nitrites.  The  bacteria  in  this  part  of  the  intes- 
tinal tract  evidently  are  the  nitrite-splitting  factors, 
whereas  those  in  the  stomach  and  small  intestines  allow 
the  bismuth  subnitrate  to  pass  into  the  large  intestines 


188       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

without  liberation  of  quantities  of  nitrites  sufficient  to 
cause  poisoning. 

The  fatal  cases  thus  far  reported  were  all  suffering 
from  intestinal  diseases,  especially  diarrhea  or  constipa- 
tion, which  suggests  that  the  intestinal  putrefaction  ac- 
celerated the  nitrite  formation  and  rapid  poisoning. 

During  the  past  three  years  the  author1  has  employed 
bismuth  subnitrate  quite  extensively  in  the  treatment  of 
empyema,  sinus,  and  abscess  cavities  by  injecting  a  mix- 
ture containing  33-percent  bismuth  subnitrate  incorpo- 
rated in  petrolatum  into  the  cavities.  The  question  as 
to  what  became  of  the  bismuth  paste  after  the  injection 
arose.  A  study  of  the  subject  revealed  the  fact  that  if 
the  paste  did  not  discharge  from  the  sinus  soon  after  in- 
jection, but  was  retained,  it  became  encapsulated  and  ab- 
sorbed. In  nonresilient  cavities,  such  as  bone  cavities, 
the  mass  is  penetrated  from  all  sides  by  fibroblasts  and 
gradually  replaced  by  connective  tissue,  while  in  col- 
lapsible cavities,  such  as  the  pleura,  the  expanding  lung 
gradually  replaces  the  slowly  absorbing  bismuth  paste. 
This  can  be  proven  by  taking  radiographs  at  certain  in- 
tervals of  the  region  injected.  This,  then,  proves  that 
the  bismuth  paste  is  absorbed,  and  the  question  arises, 
How  is  the  bismuth  excreted,  and  is  its  absorption  harm- 
ful? 

Harnack2  states  that  bismuth  subnitrate  is  slowly  ab- 
sorbed and  slowly  eliminated.  Orfilla  found  bismuth 
subnitrate  in  the  liver.  M.  M.  Bergeret3  states  that  bis- 
muth subnitrate  is  found  in  the  urine  and  in  the  serous 
exudates  a  few  hours  after  administration.  In  rabbits 
the  administration  of  a  few  grains  could  be  detected  in 
the  spleen,  muscles,  and  blood.     Professor  E.  S.  Wood4 


1  Beck:  Illinois  Medical  Journal,  April  and  July,  1908. 

2  Harnack:  Arzneilehre,  1883,  p.  383. 

3  Bergeret:  Journal  de  l'Anatomie,  1873,  p.  242. 

4  Wood:  Transactions  of  American  Neurological  Association,  1883,  p.  23. 


BISMUTH  POISONING.  189 

has  detected  bismuth  in  the  urine  four  weeks  after  ad- 
ministration, proving  its  slow  absorption.  We  may, 
therefore,  conclude  that  the  bismuth  is  slowly  absorbed 
and  slowly  eliminated. 

Before  attempting  to  answer  the  question — Is  the  ab- 
sorption of  bismuth  paste  harmful? — we  must  decide 
whether  the  harmful  effects  noted  in  the  reported  cases 
are  due  to  the  absorption  of  the  liberated  nitrites  or  of 
the  bismuth  itself. 

In  my  experience  with  the  injection  of  bismuth  petro- 
latum into  sinus  and  abscess  cavities  I  have  not  encoun- 
tered a  single  case  in  which  the  train  of  symptoms  would 
correspond  to  that  of  an  acute  nitrite  poisoning.  I  have, 
therefore,  concluded  that  the  injection  of  the  paste  does 
not  produce  a  nitrite  poisoning. 

The  first  case  in  which  I  observed  symptoms  of  true 
bismuth  intoxication  as  a  result  of  bismuth  paste  was  a 
case  of  empyema  pleurae,  in  which  I  injected  into  the 
pleural  cavity  720  grams  of  33-percent  bismuth  paste, 
which  was  retained  there  for  six  weeks.  "A  desquama- 
tive nephritis  developed,  albuminuria  was  present,  with 
rapid  loss  of  previously  gained  weight,  and  the  blue  bor- 
der around  the  teeth  appeared.  As  soon  as  the  bismuth 
paste  was  withdrawn  by  means  of  olive  oil  all  the  symp- 
toms disappeared,  and  the  patient  regained  his  weight 
in  a  few  weeks. 

I  desire  to  cite  a  case  which  I  saw  in  consultation,  and 
reported  in  the  New  York  Medical  Journal,  January  2, 
1909,  in  which  the  bismuth  injections  had  caused  severe 
bismuth  intoxication,  and  after  this  abated  the  patient 
died.  Post-mortem  examination  and  complete  analysis 
throw  some  light  on  the  pathology  of  this  affection. 

Case  7.  R.,  a  lawyer,  aged  57,  for  many  years  an  invalid,  had  a 
tuberculosis  of  his  hip  since  1896.     After  extensive  operations  he  re- 


190       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

tained  several  sinuses,  which  discharged  large  quantities  of  foul  pus. 
In  March,  1908,  his  sinuses  had  been  injected  by  the  house  physician 
twenty  times  in  a  period  of  sixty  days  with  a  33-percent  bismuth  pet- 
rolatum paste,  the  total  amount  representing  about  400  grams  of  pure 
bismuth  subnitrate.  While  his  general  condition  improved  at  first  and 
his  sinuses  had  healed  up,  all  typical  signs  of  bismuth  intoxication 
gradually  developed.  The  mucous  membrane  of  the  mouth  and  gums 
became  bluish-black,  with  ulcerations;  teeth  became  loose  and  lips 
edematous.  He  experienced  great  thirst,  diarrhea,  and  had  desquama- 
tive nephritis.  The  symptoms  gradually  abated,  and  he  became  well 
enough  to  resume  his  work  as  an  attorney,  and  for  two  months  was 
active  in  his  vocation.  A  radiograph  taken  of  his  pelvis  demonstrates 
that  there  were  only  small  quantities  of  bismuth  within  the  tissues. 

August  1, 1908,  he  fell,  injured  his  wrist,  and  a  large  abscess  formed, 
which  was  operated  on  by  Dr.  V.  Verity.  A  large  area  of  necrosis  fol- 
lowed. From  this  time  his  temperature  varied  from  99°  to  101.5°  F. 
He  lost  in  strength,  his  urine  was  loaded  with  casts  and  albumin,  his 
heart  became  weaker  and  irregular,  and  he  died  August  16,  1908. 

Post-mortem  examination,  made  by  Dr.  Gehrmann  and  myself, 
showed  the  following  conditions: 

Abdominal  Cavity.  A  small  amount  of  fluid  present.  No  adhe- 
sions or  evidence  of  tumors  or  inflammatory  exudates. 

Liver.  Normal  in  size,  dark-brownish  in  color.  Section  fails  to 
show  any  noticeable  changes. 

Spleen.    Normal  size,  but  unusually  dark;  quite  soft. 

Pancreas.     Negative. 

Intestines.     Somewhat  distended  with  gas,  but  otherwise  negative. 

Vermiform  Appendix.     Negative. 

Mucous  Membrane  of  Intestines.     Shows  dark  color,  very  marked. 

Kidneys.  Normal  in  size.  External  surface  of  both  shows  some 
evidence  of  beginning  contraction,  as  the  capsule  is  irregularly  de- 
pressed. Sections  show  both  kidneys  to  be  of  dark  color,  with  the 
cortical  markings  not  as  distinct  as  in  a  normal  organ. 

Pelvis  and  Ureters.  Free.  On  the  right  side  in  the  peivis  the 
retroperitoneal  tissue  appears  gelatinous,  of  a  whitish,  glistening  ap- 
pearance, as  if  filled  with  a  foreign  substance.     (No  bismuth.) 

Chest.  Pericardium  negative.  Heart  about  the  size  of  subject's 
fist.  Heart  muscle  rather  softer  than  normal.  Valves  negative  and 
coronary  arteries  negative. 

Lungs.  Few  adhesions  about  apices  on  both  sides.  Some  hypos- 
tasis on  both  sides.     Otherwise  negative. 

Bones  of  Thorax  and  Spine.  Inspection,  as  far  as  possible,  fails  to 
show  fractures,  tumors,  or  inflammatory  changes. 

Head.     Not  posted. 

The  microscopical  examination  of  the  tissues  from  the  liver,  spleen, 
kidneys,  heart  muscle,  and  intestine,  and  the  chemical  analysis  of  tis- 
sues, were  made  by  Dr.  Maximilian  Herzog,  and  his  report  is  as  fol- 
lows: 


BLSM  TIT  rr  POISONING. 


191 


Liver.  The  liver  parenchyma  cells  in  general  do  not  show  any 
marked  pathological  changes.  Some  cloudy  swelling  is  noticeable  here 
and  there,  but  the  process  is  not  at  all  extensive;  on  the  contrary,  it 
is  quite  limited.  There  is  very  little  fatty  infiltration  and  fatty  de- 
generation. Quite  a  number  of  parenchyma  cells  show  bile  granules 
in  their  paraplasm.  Whether  the  latter  also  contain  here  and  there 
bismuth  is  a  question  which  can  not  be  definitely  decided,  as  we  do 
not  know  of  any  microchemical  reaction  for  bismuth.  It  appears,  how- 
ever, that  we  find  frequently  in  liver  cells  granules  darker  than  the 
bile  granules  and  that  they  are  bismuth  granules.     The  latter  can  first 


Pig.  74.  Photomicrograph  of  section  of  liver  about  four  niicra  thick.  In  the 
center  of  an  interlobular  vein,  to  the  right  and  above  a  sublobular  vein.  The 
intima  of  both  lined  with  bismuth.     Magnification,  210  diameters. 


be  seen  distinctly  and  beyond  doubt  in  the  interlobular  capillaries. 
Here  we  see  the  dark  granules  in  the  lumen  of  the  small  vessels  and 
crowded  in  fusiform  cells,  probably  the  star  cells  of  Kupfer.  In  the 
interlobular  veins  bismuth  is  present  to  a  large  extent;  it  is  found 
in  the  vascular  endothelium  and  deposited  in  the  form  of  fine  granules 
on  the  free  surface  of  the  intima.  Occasionally  one  sees  in  the  inter- 
lobular connective  tissue  a  vessel,  apparently  a  sublobular  vein,  which 
likewise  contains  bismuth.  (Fig.  74.)  But  this  point  is  not  clear  be- 
yond doubt,  as  is  the  presence  of  bismuth  in  the  portal  system.  Bile 
capillaries  containing  bismuth  can  be  distinguished  here  and  there 
between   the  liver   cells;    bismuth   is   also   occasionally  found   in   the 


192       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

small  interlobular  bile  ducts,  but  the  biliary  ducts  and  capillaries  are 
generally  collapsed  and  empty. 

Kidneys.  The  renal  tissue  shows  chronic  interstitial  changes,  with 
hyaline  degeneration  of  a  considerable  number  of  glomeruli.  A  few 
of  the  degenerated  hyaline  spheres  contain  lime  salts.  Some  tubules 
contain  hyaline  casts;  besides,  here  and  there  the  tubular  epithelia 
show  marked  cloudy  swelling.  There  is  no  bismuth  present  in  the 
renal  sections. 

Spleen.  There  is  some  thickening  of  the  capsule  and  of  the  tra- 
becular noticeable.  The  pulp  spaces  are  not  very  distinct — well 
crowded  with  erythrocytes  and  leucocytes.  The  Malpighian  bodies  are 
not  well  defined.  Some  bismuth  is  present  in  the  shape  of  amorphous 
granules,  and  denser  masses  in  the  pulp  spaces. 

Myocardium.  Striation  is  not  very  distinct;  there  is  here  and  there 
a  fine  vacuolation;  also  occasionally  some  cells  which  show  the  pig- 
mentation of  brown  atrophy.  But  these  pathological  changes  are  very 
moderate  in  degree.    A  few  subpericardial  round  cells  foci  are  present. 

Intestinal  tissue.  Nothing,  except  a  very  few  thick,  irregular  sec- 
tions were  accessible  for  examination.  These  show  an  extensive  in- 
filtration of  the  mucosa  with  bismuth.  The  lymphoid  tissue  likewise 
shows  bismuth,  and  much  of  the  latter  is  found  in  the  veins  of  the 
submucosa. 

The  chemical  examination  resulted  as  follows: 

Heart  Muscle.     A  faint  trace  of  bismuth. 

Spleen.     Very  small  piece.     Distinct  reaction  for  bismuth. 

Liver.  Contained  0.13  percent  of  bismuth  oxide.  The  tissue  was 
pressed  fairly  dry  between  filter  paper.  Weight,  2,292  grams;  total  ash 
weight,  0.030  grams,  in  which  bismuth  weighed  0.003  grams. 

From  the  above  microscopical  examination  it  might 
appear  that  the  bismuth  was  first  absorbed  into  the 
lymphatics — that  it  was  transported  to  and  excreted  into 
the  intestines.  Much  was,  however,  reabsorbed  by  the 
portal  circulation  and  transported  to  the  liver,  to  be  there 
excreted  into  the  bile  passages.  There  is  no  evidence  that 
any  of  the  bismuth  was  excreted  by  the  kidneys. 

While  this  case  presented  the  symptoms  of  bismuth 
intoxication,  and  its  absorption  was  proven  post-mortem 
by  microscopical  examination  and  chemical  analysis,  the 
question  is  still  open  as  to  whether  the  absorption  and 
presence  of  metallic  bismuth  in  the  tissues  was  the  direct 
cause  of  death.     The  pathological  changes  in  the  liver, 


BISMUTH  POISONING.  193 

spleen,  and  heart  muscle  did  not  indicate  that  a  severe  de- 
structive process,  which  would  interfere  with  function, 
was  going  on.  The  interstitial  nephritis  was  evidently 
not  due  to  the  bismuth  absorption,  as  the  renal  tissue  was 
free  from  deposits  of  the  metal,  and  the  pathological  con- 
dition found  could  be  expected  in  an  old  man  who  had  for 
years  suffered  from  a  chronic  suppurative  disease.  Dr. 
Verity  reports  that  the  patient  was  treated  by  him  ten 
years  ago  for  chronic  nephritis. 

Dr.  H.  Eggenberger,1  from  the  clinic  of  Professor 
Wilms,  of  Basel,  reports  a  fatal  case  of  bismuth  intoxica- 
tion subsequent  to  the  injection  of  a  psoas  abscess  in  a 
child  7  years  old.  Thirty  grams  of  the  paste  were  in- 
jected and  retained  for  six  weeks.  Stomatitis  developed, 
resembling  mercurial  intoxication;  pulse  rose  to  130,  and 
a  picture  of  toxic  cortex,  such  as  is  often  observed  in 
uremia,  developed.  The  abscess  cavity  was  evacuated, 
but  the  child  died  a  few  days  later. 

Autopsy  revealed  no  anatomical  changes,  except  a 
hyperemic  condition  of  the  central  nervous  system  and 
small  hemorrhagic  spots  in  the  mucous  membrane  of  the 
stomach.  The  intestinal  follicles  were  red  and  swollen, 
and  on  the  valvula  Bauhini  a  greenish-brown  ulceration, 
2  to  3  centimeters  in  circumference,  was  found. 

In  a  resume,  Eeich,2  of  Professor  Bruns'  clinic,  has  col- 
lected from  the  literature  thirteen  cases  of  bismuth  in- 
toxication, of  which  six  terminated  fatally  and  seven  re- 
covered. This  series  includes  the  three  cases  previously 
reported  by  me,  which,  however,  occurred  in  the  practice 
of  other  physicians  who  called  me  to  see  them.  The  re- 
maining three  cases  were  those  of  Kaufmann  (Cook 
County  Hospital),  Eggenberger,  and  Reich. 


1  Eggenberger:  Centralblatt  fiir  Chirurgie,  1908,  No.  44. 

3  Reich:  Beitrage  zur  Klinische  Chirurgie,  1909,  bd.  65,  h.  1. 


194       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

Since. then  Matsuoka,1  of  Japan,  reported  three  cases, 
of  which  two  were  fatal  and  one  recovered. 

Most  of  these  cases  occurred  in  the  early  period  of  the 


Fig.  75.     Large  quantities  of  bismuth  paste  retained  in  pelvis,  causing  absorp- 
tion.    Complete  recovery  after  washing  out  with  olive  oil. 


development  of  the  bismuth  paste  treatment,  and  usually 
in  one  of  the  first  cases  in  which  it  was  tried.  Since  the 
various  warnings  and  my  publications  as  to  its  preven- 


1  Matsuoka:  Deutsche  Zeitschrift  fur  Chirurgie,  bd.  102,  s.  508. 


BISMUTH  POISONING. 


195 


tion,  the  reports  of  bismuth  poisoning-  ceased  to  appear 
in  the  literature,  in  spite  of  the  fact  that  its  use  has  been 
extended  into  all  parts  of  the  world.  This  indicates  that 
the  paste  is  used  more  judiciously  and  the  intoxication  is 
avoided,  thus  eliminating-  the  one  objectionable  element. 
My  brothers  and  I  consider  ourselves  fortunate  in  not 


Pig.  75  A.  Diagrammatic  illustration  of  Fig.  75.  A,  bismuth  paste  in  pelvic 
cavity ;  B,  sacrum  ;  C,  greater  trochanter  ;  D,  intrapelvic  abscess,  cavity  close  to 
rectum  ;  E,  symphysis  pubis  ;  F,  femur. 


having  had  a  fatal  case  in  our  large  series,  especially  so 
as  we  had  no  one  to  put  us  on  our  guard  against  such  con- 
tingency. Fortunately  I  discovered  the  onset  in  the  first- 
case,  an  empyema,  early  enough  to  prevent  a  fatality,  and 
from  this  lesson  we  learned  to  anticipate  and  prevent  its 
occurrence. 


196       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

Prevention  of  Bismuth  Poisoning. 

The  prevention  consists  of  not  allowing  large  quanti- 
ties of  the  paste  to  remain  in  the  body  for  absorption. 
Should  the  symptoms  appear,  the  paste  must  be  removed 
by  washing  out  the  cavity  with  warm  olive  oil.  The 
sterile  oil  is  injected  and  retained  for  twelve  to  twenty- 
four  hours,  in  order  to  produce  an  emulsion,  which  should 
be  withdrawn  by  means  of  suction.  After  its  removal  all 
symptoms  will  promptly  disappear.  Scraping  out  the 
paste  with  a  scoop  is  a  dangerous  procedure,  because  it 
opens  fresh  channels  for  absorption. 

The  following  case  illustrates  the  prevention  of  bis- 
muth poisoning: 

R.  W.,  aged  33,  fell  from  a  horse  at  the  age  of  15,  injuring  his 
left  hip.  Three  months  later  an  abscess  developed,  which  ruptured 
spontaneously.  Within  a  year  the  limb  shortened  four  and  one-half 
inches,  and  five  sinuses  about  the  hip  developed  and  persisted  in  dis- 
charging pus  for  the  next  seventeen  years.  In  the  fall  of  1908  the 
bismuth  injections  were  begun  at  his  home.  The  first  few  injections 
were  made  by  his  physician,  and  thereafter  (he  living  in  a  rural  dis- 
trict) the  treatment  had  to  be  continued  at  home  by  the  patient's 
wife.  She  "faithfully"  injected  every  day,  and  after  thirty  days  he 
developed  typical  signs  of  bismuth  absorption — namely,  blue  ulcers  of 
the  gums,  headache,  loss  of  weight,  etc.  The  radiograph  (Fig.  75) 
demonstrates  that  enormous  quantities  of  paste  have  accumulated  in 
pelvic  cavities,  with  no  outlet  for  their  return,  and  thus  their  absorp- 
tion. 

The  sinuses  were  immediately  washed  out  with  warm  olive  oil,  and 
within  twenty-four  hours  nearly  all  the  paste  was  withdrawn  by  means 
of  a  suction  pump.  Symptoms  of  bismuth  poisoning  subsided  within 
four  days,  but  the  sinuses  continued  to  discharge.  Four  weeks  later 
I  injected  30  grams  of  paste.  The  secretion  changed  from  that  of  pus 
to  serum,  and  two  weeks  later  the  sinuses  closed. 

Another  illustration  is  the  following  case  of  empyema: 

B.  had  pneumonia,  followed  by  empyema,  in  the  fall  of  1909.  A  re- 
section of  one  rib  was  performed  and  drainage  instituted.  The  sup- 
puration continued,  however,  for  several  months,  when  he  was  brought 
to  me  for  treatment.  After  estimating  the  size  of  the  cavity  by  radio- 
graph, I  injected  16  ounces  of  the  33-percent  bismuth-vaselin  paste. 
Radiograph    (Fig.   76)    shows  the  size  of  the  cavity.     The  paste  was 


BISMUTH    POISONING. 


197 


retained  for  ten  days,  and  during  this  time  the  patient  felt  absolutely 
well,  but  thereafter  he  began  to  complain  of  lassitude  and  loss  of  appe- 
tite. An  examination  of  the  mouth  showed  the  first  symptoms  of  bis- 
muth absorption — i.  e.,  a  bluish  discoloration  at  the  margins  of  the 
gums  and  also  bluish   rings  around  the  follicles  of  the  tonsils.     Within 


Fig.   76.      Empyema  filled  with  bismuth  paste,  causing  symptoms  of  absorption 
in  two  weeks.     Prompt  removal  of  paste  resulted  in  complete  recovery  and  cure. 


the  next  twenty-four  hours  small  ulcerations  began  to  appear  back  of 
the  wisdom  teeth.  The  chest  cavity  was  at  once  washed  out  with 
warm  olive  oil  and  the  paste  withdrawn  with  suction  pump.  (Fig.  77.) 
The  cavity  was  refilled  with  sterile  vaselin  in  order  to  prevent  the 
entrance  of  air.     The   secretions   in  the  meantime   had   become   abso- 


198       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

lutely  sterile  and  reduced  in  quantity.  The  symptoms  of  bismuth 
absorption  at  once  began  to  disappear,  and  within  three  weeks  not  a 
sign  of  them  remained.  The  cavity  was  treated  by  repeated  suction 
to  expand  the  resilient  lung.  Two  more  injections  of  a  10-percent  bis- 
muth paste  were  given  at  intervals  of  ten  days.  Finally  all  the  paste 
was  withdrawn,  the  cavity  closed,  and  now  the  contracted  lung  has  ex- 


Fig.  77.      Method   of  withdrawing   mixture    of   paste    and   olive   oil   twenty-four 
hours  after  injection  of  the  latter. 


panded  sufficiently  to  fill  out  the  entire  space  first  occupied  by  the 
bismuth  paste.  The  sinus  is  closed,  and  the  patient  has  gained  greatly 
in  weight  and  general  health. 

We  have  shown  that  bismuth  poisoning  can  be  pre- 
vented, and  when  it  does  appear  it  can  be  checked.  Thus 
we  are  able  to  eliminate  the  objectionable  feature  of  the 
bismuth  paste  treatment. 


CHAPTER  XV. 

BISMUTH     PASTE     IN     THE     TREATMENT     OF 

CHRONIC  SUPPURATIVE  DISEASES  OF  THE 

NOSE,  ACCESSORY  SINUSES,  EARS, 

AND  MASTOID  PROCESS. 

BY  JOSEPH   C.    BECK,    M.    D.1 

One  of  the  first  cases  of  the  head  treated  by  means  of 
bismuth  paste,  and  subsequently  reported  by  Dr.  Emil 
Beck,  was  a  tuberculous  osteoperiostitis  of  the  orbit,  with 
abscess  and  fistulous  formation,  in  a  child,  and  so  strik- 
ing was  the  therapeutic  result  that  I  from  that  time — 
January  24,  1908 — began  to  employ  this  method  of  treat- 
ment with  great  enthusiasm. 

In  order  to  determine  the  value  and  limitations  of  bis- 
muth paste  in  chronic  suppurations  in  the  head  and  neck, 
I  decided  to  experiment  on  every  pathological  condition 
in  which  the  principles  underlying  the  action  of  bismuth 
paste  appeared  to  be  indicated. 

In  May,  1908,  I  made  a  preliminary  report  before  the 
Chicago  Otolaryngological  Society  on  the  injection  of 
bismuth  paste  in  antrum  suppurations,  and  in  October, 
1908,  I  made  a  complete  report  before  the  Chicago  Med- 
ical Society  of  319  cases  of  the  following  conditions  and 
results  obtained. 

The  results  in  this  report  were  not  final,  as  a  large  per- 
centage of  these  cases  were  at  the  time  still  under  treat- 
ment. 


1  Surgeon  to  the  North  Chicago  Hospital  and  Cook  County  Hospital: 
Clinical. Professor  of  Otolaryngology.  College  of  Physicians  and  Sur- 
geons, Chicago;  Professor  of  Otolaryngology,  Eye,  Ear,  Nose,  and  Throat 
College,   Chicago. 

199 


200       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


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§13 


202       BISMUTH  PASTE  IX  CHRONIC  SUPPURATIONS. 

After  more  than  one  year  of  observation  of  these  cases, 
treated  for  finding  the  limitations  of  the  bismuth  paste 
in  nose  and  ear  work,  I  came  to  the  following  conclusions : 

1.  That  in  atrophic  rhinitis,  while  scab-forming  and 
odor  were  controlled  during  the  period  of  treatment,  the 
curative  effect  upon  the  atrophic  condition  was  negative, 
and,  as  the  injections  were  more  disagreeable  than  other 
methods  of  treatment,  I  have  discontinued  their  use  in 
this  affection. 

2.  As  a  primary  dressing-  following  submucous  resec- 
tion of  the  septum,  I  have  discontinued  its  use,  owing  to 
the  possibility  of  some  of  the  paste  getting  in  between 
the  mucoperichondrial  flaps  and  thus  preventing  union. 

3.  In  ethmoid  suppurations  I  have  found  that  injec- 
tions were  of  no  avail,  as  the  paste  can  not  reach  all  the 
infected  cells,  and  consequently  I  do  not  employ  it  in  this 
affection;  but  as  a  primary  dressing  after  exenteration 
I  employ  it  regularly,  as  will  be  shown  in  this  chapter. 

4.  In  chronic  lacunar  tonsilitis  I  have  come  to  the  con- 
clusion that  no  permanent  results  could  be  obtained,  and 
therefore  it  is  of  no  greater  value  than  any  other  pallia- 
tive treatment. 

5.  In  chronic  suppuration  of  the  antrum  of  Highmore, 
and  the  frontal  and  sphenoidal  sinuses,  as  a  palliative 
treatment,  I  am  convinced  that  the  results  are  equally  as 
good  as  from  any  other  method  of  treatment.  As  a  cura- 
tive method  the  paste  has  produced  the  best  results  in 
the  radical  obliteration  of  the  frontal  sinus  and  the  an- 
trum, as  will  be  shown  later. 

6.  In  chronic  suppurations  of  the  middle  ear  I  continue 
to  employ  bismuth  paste,  and  find  that,  while  it  does  not 
cure  more  cases  than  other  palliative  means  of  treatment 
(the  pathologic  condition  usually  precluding  such  a  pos- 


NOSE,  EARS,  MASTOID  PROCESS.  203 

sibility),  I  am  nevertheless  certain  that  in  cases  which 
are  curable  by  nonoperative  measures  the  paste  treat- 
ment will  stop  the  suppuration  quicker  and  recurrences 
will  be  less  frequent. 

7.  As  a  primary  dressing  (at  the  time  of  the  opera- 
tion) in  radical  mastoid  with  plastic  I  have  discontinued 
the  employment  of  bismuth  paste,  owing  to  the  fact  that 
some  of  the  paste  may  find  its  way  underneath  the  flaps 
and  delay  healing.  As  a  secondary  dressing,  however, 
just  as  soon  as  union  has  taken  place,  I  know  of  no  bet- 
ter dressing  to  control  the  suppuration  and  stench,  which 
we  are  accustomed  to  see  in  these  cases,  than  the  applica- 
tion of  bismuth  paste. 

8.  As  a  framework  for  bone  formation  in  the  simple 
mastoid  operation,  with  primary  closure  of  the  wound,  I 
employ  it  only  in  the  selected  cases,  where  the  bony  walls 
of  the  mastoid  are  absolutely  intact,  and  when  the  char- 
acter of  the  infection  is  not  of  a  virulent  type. 

9.  As  a  secondary  dressing  in  the  simple  mastoid  cases, 
I  am  certain  there  is  no  other  method  that  will  compare 
with  the  results  in  obtaining  rapid  and  permanent  clos- 
ure of  the  retroauricular  wound. 

10.  In  otitis  externa  eczematosa,  filling  the  external 
auditory  canal  with  the  paste  is  preferable  to  other 
methods  of  local  application. 

11.  The  simplest  means  of  controlling  intranasal 
hemorrhage,  especially  when  it  originates  from  the  an- 
terior or  upper  regions,  is  the  injection  of  semi-solid  bis- 
muth paste  No.  2.  The  difficulty  of  controlling  bleeding 
from  the  posterior  and  lower  portions  of  the  nasal  cavity 
is  due  to  the  inability  to  retain  sufficient  quantity  to  plug 
that  region,  as  it  usually  drops  into  the  throat. 


204       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

Treatment  of  Suppurations  of  the  Nose  and  Its  Accessory 

Sinuses. 

In  considering  the  treatment  of  chronic  suppurative 
diseases  of  the  nose,  I  refer  especially  to  the  accessory 
sinuses,  as  suppuration  of  the  cavity  proper  is  usually 
secondary  to  the  above-named  structures,  although 
ozena,  atrophic  rhinitis,  and  suppurations  associated 
with  foreign  bodies  are  frequently  met  with.  Before 
considering  the  treatment  of  the  sinuses  it  will  be  well 
to  mention  some  anatomical,  physiological,  and  patho- 
logical points,  so  far  as  these  bear  relation  to  bismuth 
paste  treatment. 

Anatomical  Points. — The  nasal  accessory  sinuses  are 
solid-walled  cavities,  oftentimes  divided  by  partial  septa, 
and  irregular  in  shape,  the  ethmoidal  labyrinth  being 
multicellular.  They  are  neither  compressible  nor  dis- 
tensible, and  are  lined  by  a  modified  mucous  membrane. 

The  openings  leading  into  them  from  the  nasal  cavity 
are  so  located  as  to  make  the  introduction  of  a  cannula  or 
sound  somewhat  difficult,  and  thus  the  treatment  can  be 
carried  out  advantageously  only  by  those  who  are  famil- 
iar with  the  technic  and  the  use  of  reflected  light. 

Physiological  Points. — 1.  These  cavities  are  resonators 
to  the  voice. 

2.  They  impart  warmth  and  moisture  to  the  inspired 
air. 

3.  An  accessory  function  of  the  sense  of  smell  is  at- 
tributed to  them. 

4.  Their  hollow  construction  serves  the  purpose  of  mak- 
ing the  bones  of  the  head  very  light. 

5.  The  large  surface  of  mucous  membrane  has  a  power- 
ful absorptive  function. 

Pathological  Points. — There  exists  usually  the  myx- 
omatous  degeneration   of  the   mucous   membrane   with 


NOSE,  EARS,  MASTOID  PROCESS.  205 

polypoid  formation.  In  very  chronic  cases  there  is  fre- 
quently superficial  osteitis,  a  necrosis  with  accompany- 
ing granulations. 

These  points  must  all  be  borne  in  mind  in  the  treat- 
ment. Without  a  perfect  knowledge  of  them,  one  will 
scarcely  be  able  to  explain  the  difficulties  in  the  treatment 
of  these  cavities  compared  with  the  treatment  in  other 
parts  of  the  body. 

It  must  be  stated  at  this  time  that  only  chronic  sup- 
purative conditions  should  be  treated  with  bismuth  paste 
— never  acute  ones. 

The  treatment  is  divided  into  two  subdivisions — name- 
ly, (A)  palliative  and  (B)  radical,  or  obliterative. 

The  formulae  used  in  the  treatment  of  the  suppurative 
conditions  of  the  nose  and  ear  are  the  same  as  used  in 
other  parts  of  the  body;  the  technic  and  instruments  are, 
however,  somewhat  different. 

Instruments. — In  Fig.  78  are  shown  the  syringes  and 
cannulas,  the  use  of  which  is  described  in  the  technic  of 
treating  the  various  conditions. 

(A.)     Palliative  Method. 

Injection  of  Antrum  of  Highmore.  Condition  1. — An 
antrum  which  has  not  previously  been  treated  surgically. 
Position  of  patient — sitting.     Cocaine  anesthesia. 

By  means  of  trocar  the  antrum  is  punctured  in  the 
usual  manner,  and  without  previously  irrigating  it  the 
syringe  proper  is  adjusted  by  its  bayonet  joint  and  the 
cavity  injected  to  distention. 

The  middle  meatus  is  temporarily  packed  with  cotton 
in  order  to  prevent  a  too  free  escape  of  the  paste  while 
injecting.  A  small  pad  of  cotton  is  placed  against  the 
opening  created  by  the  trocar,  and  the  patient  kept  quiet 


206       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 


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NOSE,  EARS,  MASTOID  PROCESS.  207 

for  about  ten  minutes,  to  insure  the  paste  remaining  in 
the  cavity. 

Condition  2. — An  antrum  which  has  an  opening  in  the 
canine  fossa  or  socket  of  a  tooth.  Position  of  patient- 
sitting,  head  slightly  reclining;  lip  retracted. 

The  middle  meatus  is  firmly  packed  under  the  middle 
turbinal,  so  as  to  block  the  natural  opening;  then  the 
olive  tip  of  the  syringe  is  put  to  the  existing  opening  of 
the  canine  fossa  or  to  the  alveolar  openings,  and  the 
cavity  is  injected.  The  cotton  is  then  removed  from  the 
nose.  It  is  well  to  pack  the  external  openings  either  with 
a  semi-solid  rubber  plug  mounted  on  a  partial  dental 
plate  or  by  cotton,  to  prevent  the  escape  of  the  paste  or 
entrance  of  food  into  the  antrum. 

Condition  3. — An  opening  exists  in  the  lateral  wall  of 
the  nose  in  the  inferior  meatus.  The  patient's  head  is 
placed  on  the  side  which  is  to  be  injected. 

The  cannula  is  passed  into  the  antrum,  cotton  packed 
well  about  it  in  order  to  insure  filling  the  cavity  to  dis- 
tention, and  the  antrum  injected  until  some  of  the  paste 
returns  along  the  cotton  packing.  The  cannula  is  with- 
drawn, but  the  cotton  packing  is  allowed  to  remain  for 
about  half  an  hour,  until  the  paste  has  become  set. 

Injection  of  Ethmoidal  Labyrinth. — These  cells  can  not 
be  treated  by  injections,  as  it  is  anatomically  impossible 
to  inject  each  individual  cell.  There  is,  however,  a  dis- 
tinct use  of  the  paste  as  a  primary  dressing  in  operations 
of  middle  turbinectomy  and  ethmoid  curetment.  This  is 
accomplished  as  follows :  As  soon  as  the  primary  bleeding 
ceases,  the  patient  is  instructed  to  close  the  post-nasal 
space  from  the  pharynx  by  having  him  repeat  rapidly  the 
word  "kick."  Simultaneously  one  applies  the  olive  tip 
of  the  syringe  to  the  nostril  so  as  to  obliterate  it,  and  in- 
jects the  cavity  to  the  sensation  of  distention.     Some  of 


208       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

the  paste  will  return  along  the  olive  tip  and  into  the  naso- 
pharynx when  the  soft  palate  is  relaxed. 

The  paste  employed  for  this  purpose  is  formula  No.  2, 
which  is  injected  in  as  solid  a  form  as  is  possible  to  force 
from  the  syringe.  This  dressing  remains  in  the  nasal 
cavity  until  the  next  morning,  and  by  its  presence  pre- 
vents bleeding,  adhesions,  and  decomposition  of  secre- 
tions. It  is  best  if  the  patient  does  not  walk  very  much 
immediately  after  the  injection,  so  as  not  to  dislodge  the 
paste.  It  becomes  fixed  in  the  exenterated  ethmoidal 
area.  In  this  connection  it  may  be  stated  that  there  is 
positively  no  such  blocking  of  the  nasal  cavity  as  to 
cause  any  retention,  and,  in  fact,  it  has  been  proven  that 
the  bismuth  paste  dressing  is  an  excellent  drain,  the  drain- 
age taking  place  between  the  nasal  wall  and  the  bismuth 
dressing.  There  is  no  need  of  removing  the  paste;  most 
of  it  will  run  out  or  will  be  blown  out,  and  what  remains 
is  absorbed.  In  the  use  of  this  method  of  dressing  it  has 
been  found  that  practically  no  after-treatment  is  neces- 
sary. 

Injection  of  Frontal  Sinus. — Patient  semi-reclining. 
Cocaine  and  adrenalin  anesthesia  to  naso-frontal  duct. 

The  cannula  is  passed  through  the  naso-frontal  duct, 
and,  if  the  passage  is  large,  some  cotton  is  firmly  packed 
about  the  introduced  cannula.  The  syringe  is  then  at- 
tached and  the  cavity  injected  to  the  sensation  of  dis- 
tention. Usually  one  observes  the  paste  escaping  along 
the  cannula.  Patient  should  remain  quiet  for  about  ten 
minutes,  and  a  small  cotton  tampon  remains  for  another 
hour  to  insure  the  retention  of  the  paste  in  the  sinus. 

Injection  of  Sphenoidal  Sinus. — Position  of  patient — 
same  as  for  injection  of  frontal  sinus. 

Whether  or  not  the  middle  turbinated  body  is  removed, 
the  cannula  is  passed  into  the  sinus  and  the  cavity  in- 


NOSE,  EARS,  MASTOID  PROCESS.  209 

jected  until  there  is  an  escape  of  the  paste  along  the  can- 
nula. A  tampon  is  pressed  against  the  opening  for  half 
an  hour  after  injection  to  help  the  retention  of  the  paste 
until  it  has  become  set.  Should  the  natural  opening  be 
too  small  to  pass  the  cannula,  it  should  be  enlarged,  but 
care  should  be  exercised  not  to  make  it  too  large,  else  the 
paste  will  escape.  In  case  the  opening  is  too  large  to  be- 
gin with,  or  an  operation  has  previously  been  performed 
which  left  the  large  opening,  it  is  well  to  pack  some  cot- 
ton firmly  about  the  cannula  to  prevent  the  escape  of  the 
paste. 

(B.)     Radical  Method  or  Permanent  Orliteration  of 
Accessory  Sinuses  with  the  Aid  of  Bismuth  Paste. 

The  ideal  results  aimed  at  in  the  permanent  cure  of 
chronic  suppurative  cavities,  especially  nasal  accessory 
sinuses,  is,  of  course,  a  return  to  the  normal.  This  is, 
however,  precluded  on  account  of  the  pathological 
changes  that  have  taken  place  in  the  mucous  membrane 
lining  these  cavities.  Heretofore — in  fact,  at  the  present 
time — it  has  been  the  practice  of  the  majority  of  special- 
ists to  resort  to  operations  of  enlarging  the  normal  out- 
lets of  the  sinuses,  or  making  artificial  openings,  eventu- 
ally curetting  the  diseased  mucous  membranes,  and  sub- 
sequently irrigating  them  by  all  sorts  of  astringents  and 
antiseptics.  The  results  from  such  treatment  are  very 
unsatisfactory,  and  in  the  majority  of  instances  the  sup- 
puration continues. 

As  we  can  not  expect  the  ideal  result — namely,  com- 
plete resolution — the  next  best  result  obtainable  is  un- 
questionably the  radical  obliteration,  or  exenteration,  of 
the  sinuses. 

Frontal  Sinus. — Killian  has  contributed  a  boon  to 
humanity  by  his  radical  frontal  sinus  operation.     While 


210       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

the  Killian  frontal  sinus  operation  cures  a  large  percent- 
age of  cases  of  chronic  suppuration  of  the  frontal  sinus,  it 
has  some  disadvantages:  first,  it  creates  a  considerable 
amount  of  external  deformity,  and  it  also  takes  some  time 
before  obliteration  takes  place;  second,  frequently  rein- 
fection of  the  operated  frontal  sinus  occurs  following  an 
acute  attack  of  rhinitis;  third,  there  are  quite  a  number 
of  cases  thus  operated  which  do  not  become  obliterated 
and  continue  to  suppurate. 

In  order  to  obviate  some  of  these  difficulties,  the  aid 
of  the  bismuth  paste  is  a  marked  advantage. 

Technic  in  Frontal  Sinus. 

After  opening  the  frontal  sinus  externally  sufficient  to 
inspect  the  entire  cavity,  one  will  remove  every  vestige 
of  mucous  membrane  of  the  entire  sinus.  Upon  the  thor- 
oughness of  this  procedure  depends  the  success  of  the 
obliteration.  A  probe  is  then  passed  through  the  naso- 
frontal duct  into  the  nasal  cavity  and  the  duct  curetted 
of  its  mucous  membrane,  but  not  enlarged  by  any  opera- 
tion on  the  bone  of  this  duct.  The  upper  region  of  the 
nose  is  now  firmly  packed  temporarily  with  tampon  to 
prevent  the  easy  escape  of  the  paste  while  filling  the 
sinus.  The  sinus  is  now  thoroughly  dried  of  its  blood  by 
packing  it  with  gauze  saturated  with  peroxide  of  hydro- 
gen or  adrenalin,  and  filled  completely  with  No.  2  bis- 
muth paste.  (Fig.  79.)  The  periosteum  and  skin  are 
sutured  without  any  drain,  and  about  a  half  an  hour  later, 
while  the  patient  is  still  in  the  recumbent  position,  the 
nasal  tampon  is  removed.  Should  the  paste  escape  and 
suppuration  again  occur  from  the  frontal  sinus,  then  one 
will  reinject  the  cavity  by  the  nasal  route,  as  described  in 
the  palliative  method  of  treatment  of  chronic  frontal 
sinus  suppuration. 


NOSE,  EARS,  MASTOID  PROCESS. 


211 


The  antrum  of  Highmore,  oven  after  the  most  radical 
measures,  such  as  the  Denker  or  Jansen  operations,  re- 
mains a  suppurative  cavity  because  it  communicates 
with  the  general  nasal  cavity,  although  retention  is  obvi- 
ated by  these  methods.  The  ideal  result  (aside  from  re- 
turn to  the  normal)  is  unquestionably  complete  oblitera- 


Fig.  79.  Frontal  sinus  injected  with  bismuth  paste  No.  2  by  nasal  route.  Por- 
tion of  the  bismuth  paste  in  the  ethmoid  region  and  antrum. 

tion,  and  to  that  end  the  aid  of  bismuth  paste  and  certain 
teclmic  in  the  operation  are  required. 

Technic  in  Antrum  of  Highmore. 

The  most  suitable  cases  for  this  mode  of  treatment  are. 
of  course,  such  as  have  had  no  great  amount  of  operating 
done  on  the  lateral  wall  of  the  nose  or  internal  antral 


212       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

wall,  as  any  large  communication  into  the  nose  prevents 
the  retention  of  the  paste  within  the  cavity. 

The  usual  opening  into  the  antrum  is  made  through  the 
canine  fossa,  and  as  much  as  possible  of  the  anterior  and 
external  wall  of  the  antrum  is  removed.  The  mucous 
membrane  is  now  very  thoroughly  removed  by  curet, 
great  care  being  exercised  in  curetting  the  internal  wall 
of  the  antrum,  so  as  not  to  break  into  the  nasal  cavity. 
In  some  cases  one  can  remove  the  bony  part  of  this  in- 
ternal wall  of  the  antrum,  and  then  obliteration  is  much 
more  rapid.  The  cavity  is  packed  with  peroxide  or  ad- 
renalin gauze  and  the  nasal  cavity  temporarily,  but  com- 
pletely, tamponed.  The  packing  is  now  removed  from  the 
antrum  and  the  cavity  filled  either  with  bismuth  paste 
No.  2  (Fig.  80)  if  the  antrum  is  of  small  size,  or,  prefer- 
ably, with  packing  of  gauze  strips  which  have  been  thor- 
oughly impregnated  with  bismuth  paste  No.  1.  The  ends 
of  these  gauze  strips  are  allowed  to  come  out  through  the 
gingivo-labial  margin  after  most  of  the  incision  has  been 
sutured.  The  nasal  tampon  is  removed,  and  the  patient 
remains  lying  on  the  side  of  the  operated  antrum  to  pre- 
vent the  paste  from  escaping.  The  subsequent  treatment 
of  the  cavity  filled  with  gauze  strips  is  to  remove  them  in 
about  two  or  three  days,  and  either  refill  with  similar 
strips  or  inject  bismuth  paste  No.  2.  (It  should  be  re- 
membered that  the  paste  is  to  be  used  in  fairly  cold  or 
semi-solid  consistency  in  this  procedure.)  After  the  in- 
jection with  the  paste,  drainage  is  discontinued  and  the 
wound  allowed  to  close. 

Recently  Citelli1  has  made  several  experiments  on  ani- 
mals in  filling  their  frontal  sinuses  with  the  Moorhof- 
Mosetig  plug,  and  subsequently  tried  it  on  some  chronic 
suppurative  sinuses  in  the  human,  with  the  idea  of  oblit- 


1  Citelli:  International  Centralblatt  der  Ohrenheilkunde,  April,  1910. 


N"OSE,  EARS,  MASTOID  PROCESS.  213 


Pig.  80.     Radical  operation  on  antrum  and  filled  with  paste  No.  2.     A,  antrum 
filled ;  B,  gold  tooth  filling. 


214       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

erating  these  cavities.  No  definite  data  are  given  as  to 
results. 

In  chronic  suppuration  of  the  sphenoid  sinuses  the  best 
one  can  do  is  to  remove  as  much  of  the  anterior  wall  as 
possible  and  curet  the  diseased  mucous  membrane.  The 
obliteration  of  this  cavity  is  impossible,  as  the  retention 
of  the  paste  is  difficult,  but  it  can  be  materially  reduced 
in  size  by  packing  it  with  gauze  impregnated  with  bis- 
muth paste. 

As  to  the  ethmoid  labyrinth,  when  chronic  suppuration 
is  present  within  it,  there  is  no  question  that  the  complete 
exenteration  of  every  cell  insures  the  best  chances  for  a 
permanent  cure.  Unfortunately  this  is  not  possible  in 
the  majority  of  instances  on  account  of  the  anatomical 
conditions.  When,  however,  during  this  complete  exen- 
teration at  the  time  of  operation  an  injection  of  bismuth 
paste  is  made  as  a  primary  dressing  (as  described  in  the 
previous  chapter),  the  chances  for  a  radical  cure  are  in- 
creased. 

Use  of  Paste  in  the  Nose  for  Conditions  Other  than 
Sinus  Disease. 

1.  After  actual  cautery  of  the  inferior  turbinated  body. 

— To  prevent  too  great  a  reaction,  synechia  formation, 
and  easy  loosening  of  the  eschar,  the  cavity  is  filled  with 
bismuth  paste  No.  2  and  repeated  until  the  cauterized 
surface  is  healed. 

2.  Post-operative  dressing  to  the  inferior  turbinec- 
tomy. — In  cases  where  one  did  not  require  splint  or  gauze 
packing,  the  cavity  should  be  filled  with  bismuth  paste 
No.  2.  Should  packing  be  necessary,  then  the  impregna- 
tion of  the  material  with  bismuth  paste  No.  1  furnishes 
an  excellent  dressing. 

3.  Septal  ulcer. — To  control  the  scabbing  and  bleed- 


NOSE,  EARS,  MASTOID  PROCESS.  215 

ing,  the  filling  of  the  anterior  half  of  the  nasal  cavity 
with  bismuth  paste  No.  2  once  or  twice  daily  gives  the 
best  results.  Quite  profuse  bleeding  can  be  checked  by 
this  method  in  these  cases. 

Use  of  Paste  in  Diseases  of  the  Ear  and  Mastoid  Process. 

1.  Chronic  suppurative  otitis  media  treated  with  bis- 
muth paste. — The  olive  tip  syringe,  which  has  running 
through  it  a  small  rubber  tubing,  is  fitted  snugly  into  the 
external  auditory  meatus.  The  rubber  tubing  is  pushed 
in  as  far  as  possible,  and  the  cavity  injected  with  bis- 
muth paste  No.  1.  The  purpose  of  the  rubber  tubing  is 
to  allow  the  air  to  escape,  so  that  the  paste  can  follow 
through  the  perforation  into  the  middle  ear  and  beyond 
it.  A  firm  cotton  plug  is  placed  into  the  meatus  to  re- 
tain the  paste.  Examinations  of  mastoids  in  which  the 
middle  ear  was  thus  injected  just  before  a  radical  mas- 
toid operation,  as  well  as  experiments  on  the  cadaver, 
show  that  the  paste  never  passed  beyond  the  beginning 
of  the  aditus  ad  antrum.  The  attic  as  well  as  the  entire 
middle  ear  are  filled  with  the  paste.  The  results  from 
this  treatment  are  no  more  satisfactory  than  any  other 
local  measure.  One  fact,  however,  is  noticeable — that 
the  odor  is  markedly  reduced  or  completely  destroyed. 
It  has  occurred  that  during  the  injections  patients  com- 
plained of  dizziness,  which,  however,  promptly  dis- 
appeared as  soon  as  one  removed  the  tip  of  the  syringe. 
Very  small  perforations  or  labyrinth  symptoms  are  con- 
traindications for  the  injection. 

2.  Otitis  externa  eczematosa. — The  entire  canal  is  in- 
jected with  bismuth  paste  No.  1  in  the  same  manner  as  in 
injecting  the  middle  ear. 

3.  Primary  dressing'  in  simple  mastoid  operation  by 
bismuth  paste. — In  cases  of  acute  mastoiditis  in  which. 


216       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

after  complete  exenteration  of  all  the  cells,  the  walls  of 
the  mastoid  process  remain  intact — that  is,  where  no  ex- 
posure of  either  the  lateral  sinus,  dura,  horizontal  semi- 
circular canal,  or  facial  nerve  occurred — the  following 
technic  is  employed: 

Dry  the  cavity  of  all  the  blood  and  insert  a  few  strands 
of  silkworm  gut  within  the  antrum.  Allow  these  to 
come  out  through  a  separate  small  incision  below  and 
posterior  to  the  main  one.  Fill  the  cavity  with  bismuth 
paste  No.  2  to  the  level  of  its  margins,  and  unite  the  en- 
tire incision  by  carefully  bringing  the  periosteum  over 
the  paste.  The  silkworm  drain  is  removed  as  soon  as  the 
discharge  ceases  from  the  auditory  canal,  and  the  little 
stab  wound  is  allowed  to  close.  Radiographs  taken  six 
weeks  after  operation  show  about  one-half  of  the  paste 
absorbed,  and  two  or  three  months  later  will  show  only 
traces  of  bismuth.  The  cavity  has  been  replaced  by 
much  denser  structure,  as  shown  by  comparing  radio- 
graphs of  mastoid  cavities  treated  by  allowing  the  cavity 
to  fill  with  blood  clot.  Most  of  the  cases  treated  by  the 
above-mentioned  method  have  healed  in  from  one  to 
three  weeks,  with  practically  no  deformity. 

4.  Secondary  dressing  of  the  simple  mastoid  operation 
with  bismuth  paste. — In  cases  where  one  has  allowed  con- 
siderable drainage  through  the  main  incision  the  follow- 
ing technic  is  employed: 

After  a  week  or  ten  days'  drainage  with  rubber  tube, 
gauze,  etc.,  and  when  the  discharge  from  the  external 
auditory  canal  has  ceased,  the  remaining  granulating 
cavity  is  filled  with  bismuth  paste  No.  2,  a  gauze  pad 
placed  over  it  to  retain  it,  and  bandage  applied.  The  in- 
jection is  repeated  every  other  day  until  the  cavity  is 
obliterated.  Frequently,  especially  if  the  cavity  is  not 
too  large,  the  wound  will  close  after  one  or  two  injec- 


NOSE,,  EAKS,  MASTOID  PEOOE88.  217 

tions.  The  paste  should  never  be  wiped  or  washed  out, 
nor  is  the  cavity  previous  to  the  injection  cleansed  or 
washed  in  any  way. 

In  injecting  these  mastoid  cavities  it  may  occur  that 
some  paste  finds  its  way  into  the  middle  ear,  and  even 
into  the  external  auditory  canal  and  pharynx  through 
the  Eustachian  tube.  This  is  not  desirable,  and  need  not 
occur  if  one  does  not  use  too  much  pressure  in  filling  the 
cavity,  or  if  one  just  fills  it  with  a  small  spatula.  In  the 
cases  in  which  it  occurred  it  caused  no  untoward  symp- 
toms. If  the  wound  does  not  heal  after  these  injections, 
one  may  conclude  that  there  is  necrosis  or  an  unexplored 
infected  area  somewhere  within  the  mastoid  or  middle 
ear.     In  such  cases  reoperation  is  usually  necessary. 

5.  Secondary  dressing  of  a  radical  mastoid  operation. 
— After  about  one  or  two  weeks  of  drainage  by  gauze, 
one  will  substitute  it  by  the  filling  of  the  exenterated  cav- 
ity with  bismuth  paste  No.  2.  This  is  simpler  for  the 
physician  and  very  much  easier  for  the  patient,  and  has- 
tens the  granulation  and  healing  of  the  exposed  bone. 
The  granulations  grow  very  rapidly  and  the  injection 
must  be  at  times  interrupted,  the  granulations  cauterized, 
and  the  cavity  again  packed  with  gauze,  so  as  to  obtain 
rapid  epidermization. 


CHAPTER  XVI. 
THE  USE  OF  BISMUTH  PASTE  IN  DENTISTRY. 

The  teeth  and  alveolar  process  are  subject  to  various 
chronic  suppurative  conditions,  which  the  dentist  is 
called  upon  to  treat.  Pyorrhea  alveolaris,  for  instance, 
is  a  prevalent  condition,  especially  of  old  people,  and  its 
etiology  and  treatment  have  created  for  years  an  ani- 
mated discussion  among  dentists. 

Alveolar  abscesses  and  the  resulting  sinuses  occur  so 
frequently  in  the  practice  of  the  dentist  that  a  new  and 
promising  remedy,  such  as  bismuth  paste,  will  no  doubt 
be  welcome  to  them. 

Since  the  favorable  results  obtained  with  the  paste  in 
general  surgery  are  not  confined  to  tubercular  sinuses, 
and  especially  satisfactory  results  are  obtained  in  chronic 
suppuration  of  pyogenic  origin  or  in  mixed  infections, 
there  is  no  reason  why  the  dentist  can  not  obtain  equally 
good  results  in  chronic  suppurative  conditions  of  the 
jaws,  where  the  anatomical  conditions  are  even  more 
favorable. 

The  first  tests  of  its  efficacy  in  dentistry  were  made  by 
Dr.  Rudolph  Beck,  who  presented  his  first  report  in 
January,  1909,  and  published  in  the  Dental  'Review. 

His  second  report  of  his  experience  of  more  than  two 
years  with  this  method  was  read  before  the  Illinois  State 
Dental  Society  in  May,  1910,  the  substance  of  which,  with 
a  collective  report  from  about  fifty  dental  surgeons  of 
this  country  and  Europe  who  have  applied  the  method  in 
their  practice,  comprise  this  chapter. 

218 


BISMUTH  PASTE  IN  DENTISTRY.  219 

The  following  is  an  abstract  of  Dr.  Rudolph  Beck's  re- 
port: 

Pyorrhea  Alveolaris. 

Forty-four  severe  cases,  of  which  27  were  men  and  17 
women,  ages  ranging  from  25  to  68  years,  were  selected 
for  a  test,  and  in  all  of  them  the  bismuth  treatment  was 
carried  out  in  the  same  manner.  The  results  were  as 
follows : 

Twelve  cases  were  entirely  cured  with  from  one  to 
twenty  injections;  15  were  only  temporarily  benefited; 
17  were  refractory,  no  improvement  having  been  attained 
after  sufficient  trial. 

An  analytical  study  of  these  44  cases  helped  in  deter- 
mining the  cause  of  failure.  Every  case  in  which  a  com- 
plete cure  was  effected  was  free  from  any  constitutional 
disorder,  the  affection  being  of  only  local  origin,  while  in 
the  cases  in  which  the  treatment  failed  there  existed  in 
nearly  every  instance  some  general  constitutional  dis- 
order responsible  for  the  pyorrhea.  This  fact  corrobo- 
rates our  former  assertion  that  whenever  a  constitutional 
disease — such  as  diabetes,  nephritis,  or  faulty  elimina- 
tion— is  associated  with  pyorrhea,  the  treatment  of  these 
constitutional  diseases  must  either  precede  or  accom- 
pany the  local  treatment  if  any  results  are  to  be  expected. 
This  fact  also  explains  why  only  temporary  benefit  was 
obtained  in  the  15  cases  which  responded  so  slowly  to 
treatment. 

Example  1.  Pyorrhea  of  Local  Origin. — Victor  B.,  aged  45.  clerk, 
applied  for  treatment  in  February,  1909.  First  molar  and  one  bicuspid 
were  absent.  Salivary  deposits  and  profuse  suppuration  from  the  sock- 
ets of  the  incisors  and  molars  were  present. 

The  first  treatment  was  as  follows:  Without  any  special  prepara- 
tion of  the  teeth,  the  blunt-pointed,  flexible  silver  needle  of  a  metal 
syringe,  filled  with  bismuth  paste  No.  2,  was  inserted  into  the  deepest 
part  of  the  pus  pockets,  and  then  by  gentle  and  steady  pressure  the 


220       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

paste  was  forced  into  all  recesses.  The  same  procedure  was  followed 
in  all  sockets  affected.  The  second  treatment,  two  days  later,  con- 
sisted in  removing  the  deposits  around  the  necks  and  roots  of  the 
teeth,  and  again  the  paste  was  injected  in  the  same  manner.  The  dis- 
charge changed  from  a  purulent  to  a  muco-serous  character.  After 
each  subsequent  injection  at  intervals  of  two  to  three  days  the  condi- 
tion of  the  gingiva  gradually  improved,  and  after  three  weeks'  treat- 
ment the  case  was  entirely  cured,  there  being  no  recurrence  up  to  this 
date — one  year. 

The  deposits  were  intentionally  left  undisturbed  before  the  first 
injection  because  the  scaling  is  apt  to  cause  some  laceration  and 
thus  produce  new  channels  for  infection  in  the  already  infected  area. 
By  injecting  the  paste  previous  to  the  scaling  of  deposits,  this  danger 
is  obviated  because  the  paste  is  known  to  possess  a  bactericidal  ac- 
tion, and  by  its  contact  with  diseased  tissues  for  a  time  it  places  them 
in  a  condition  favorable  for  the  removal  of  the  deposits. 


Frequency  of  Injections. 

The  number  and  frequency  of  the  injections  are  deter- 
mined by  the  response  to  treatment  in  each  individual 
case.  If,  after  the  first  injection,  the  character  of  the 
discharge  changes  to  a  serous  or  a  sero-puralent  consist- 
ency, it  is  best  to  wait  from  three  to  four  days  before  re- 
peating the  injections.  In  exceptional  cases  the  pus  dis- 
charge will  entirely  cease  after  the  second  injection,  and 
the  case  remain  cured,  but,  as  a  rule,  it  requires  from  five 
to  fifteen  injections  to  produce  good  results.  If  the  dis- 
charge persists,  the  injections  may  be  repeated  daily  for 
a  period  of  thirty  days,  and  if  after  that  time  no  improve- 
ment has  followed  it  may  be  assumed  that  the  pyorrhea 
is  due  to  some  constitutional  disease.  The  treatment  is 
then  discontinued.  Before  attempting  to  treat  a  case,  it 
is  well  to  inquire  whether  a  constitutional  disease — such 
as  diabetes,  rheumatism,  or  gout — exists,  as  in  these  cases 
the  bismuth  paste  treatment  will  not  be  effective. 

The  combination  of  bismuth  subnitrate  and  vaselin 
forms  an  excellent  means  of  treatment  for  pyorrhea 
alveolaris.     Since  the  bismuth  is  insoluble,  it  is  not  dis- 


BISMUTH  PASTE  IN  DENTI8TEY.  221 

solved  by  the  saliva,  and  the  vaselin,  being  a  semi-solid 
vehicle,  keeps  the  bismuth  in  contact  with  the  diseased 
tissues  long-  enough  to  produce  a  curative  effect. 

Chronic  Alveolar  Abscess  and  Fistula. 

A  series  of  58  cases  of  sinuses  of  the  mouth  were 
treated  with  bismuth  paste  by  Dr.  R.  Beck.  The  period 
of  the  existence  varied  from  six  months  to  fifteen  years. 
Some  of  the  cases  were  previously  treated  by  other 
methods,  but  their  persistence  speaks  for  the  inefficiency 
of  the  former  methods  employed. 

The  treatment  with  bismuth  paste  produced  the  follow- 
ing results: 

Six  cases  closed  after  the  first  injection;  3  cases  after 
two  injections;  2  cases  after  three  injections;  4  cases 
after  five  injections;  6  cases  after  from  five  to  ten  injec- 
tions, all  without  operative  interference;  9  cases  closed 
after  more  than  ten  injections,  also  without  operative  in- 
terference. 

This  is  a  total  of  30  out  of  58  cases  in  which  the  injec- 
tion of  paste  produced  a  closure  of  the  existing  sinuses, 
without  surgical  aid,  after  other  methods  had  failed  in 
the  majority  of  them. 

The  remaining  28  cases  required  surgical  interference 
as  follows:  in  8  cases  curettage  of  the  sinuses  or  excis- 
ion of  the  apices  of  the  roots  was  necessary,  and  all  cases 
closed  thereafter. 

In  16  cases  even  curettage  failed  to  produce  a  cessation 
of  the  discharge,  and  thus  the  removal  of  the  tooth  in- 
volved was  necessary  for  cure.  While  in  the  16  cases  the 
paste  was  used,  it  is  fair  to  say  that  the  sinus  in  them 
might  have  also  closed  after  the  extraction  of  the  teeth 
without  the  use  of  the  paste. 

The  remaining  3  cases  had  fistulous  tracts  not  com- 


222       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

municating  with  any  tooth,  and  their  origin  was  un- 
known. One  case  required  operative  interference,  while 
the  other  2  cases  healed  by  means  of  the  injection  alone. 
It  is  obvious  that  the  percentage  of  cures  by  this  simple 
and  painless  method  is  much  larger  than  by  any  means 
previously  employed.  Many  of  these  cases  have  been 
treated  for  years  by  very  competent  and  painstaking 
dental  practitioners  without  any  results,  and  were  cured 
by  means  of  the  injection  of  the  paste  within  a  short 
time. 

A  suitable  syringe  is  also  of  vital  importance.  The 
best  is  a  metal  syringe,  with  a  flexible,  blunt-pointed  sil- 
ver nozzle,  so  that  the  conical  tip  may  be  adjusted  to  the 
opening  of  the  sinus,  and  enough  pressure  exerted  to  al- 
low the  paste  to  reach  all  the  crevices  before  the  overflow 
would  return  around  the  sides  of  the  nozzle. 

For  the  injection  of  sinuses,  formula  No.  1  is  generally 
used,  but  at  times,  where  it  is  desirable  to  retain  the 
paste  for  a  longer  period,  it  may  be  of  advantage  to  use 
formula  No.  2,  which,  on  account  of  the  addition  of  wax 
and  paraffin,  becomes  a  little  stiffer  on  cooling.  It  is  not 
advisable,  however,  to  allow  large  quantities  of  the  paste, 
which  contains  paraffin,  to  remain  permanently  within  a 
closed  cavity  on  account  of  the  irritating  quality  of  the 
paraffin  when  retained  for  absorption. 

The  following  case  of  chronic  alveolar  abscess,  with  a 
fistulous  tract,  serves  as  an  illustration  of  this  method  of 
treatment : 

Case  2.  Chronic  Alveolar  Abscess  with  a  Fistulous  Tract. — Mrs.  E. 
R.,  aged  61.  Gives  a  history  of  developing  about  ten  years  ago  an 
abscess  above  the  second  upper  molar,  which  after  rupture  terminated 
in  a  chronic  discharging  sinus.  The  tooth  was  treated,  the  sinus  closed, 
and  the  tooth  then  filled.  Several  months  later  the  patient  noticed  a 
swelling  on  the  buccal  alveolar  process.  This  proved  to  be  a  recur- 
rence, and  after  the  abscess  ruptured  pus  kept  on  discharging  for  the 


BISMUTH  PASTE  IN  DENTISTRY.  223 

past  year,  with  only  occasional  temporary  closure.  With  this  history 
she  presented  herself  for  treatment.  Believing  that  this  sinus  origi- 
nated in  an  imperfect  root  filling,  I  first  removed  the  gutta-percha  root, 
filling,  but  found  the  canals  dry  and  odorless.  Thereupon  I  injected 
bismuth  paste  through  the  sinus  opening  to  see  if  it  would  pass 
through  the  apical  opening  into  the  tooth,  but  it  did  not.  The  pulp 
chamber  was  then  packed  with  cotton  and  the  tooth  sealed  wih  gutta- 
percha. Two  days  later  the  packing  was  removed,  but  no  pus  was 
found,  nor  could  any  paste  be  forced  into  the  tooth.  I  then  enlarged 
the  sinus  opening  by  means  of  a  sharp  round  bur  and  reinjected  the 
sinus.  Three  days  later  another  injection  was  made,  after  which  the 
sinus  closed,  and  has  remained  so  up  to  date — one  year.  Permanent 
filling  was  then  inserted. 

At  the  present  time  he  does  not  remove  the  fillings  be- 
fore injection,  unless  he  is  certain  that  an  infected  root  is 
the  cause  of  the  sinus.  The  injection  is  made  first,  and 
if,  after  a  reasonable  length  of  time,  the  sinus  shows  no 
tendency  to  close,  he  seeks  for  the  cause  in  the  root  canal. 

To  further  illustrate  the  method  of  treating  pyorrhea 
and  sinuses  of  the  mouth,  I  shall  quote  some  typical  cases 
from  the  report  of  Dr.  Rudolph  Beck: 

Histories  of  Cases  from  Dr.  Rudolph  Beck's  Series. 

Case  4.  Pyorrhea  Alveolaris  (Mild  Case,  Local  Cause). — J.  V.,  aged 
52..  merchant.  Was  treated  by  me  for  several  years  for  pyorrhea 
alveolaris,  with  only  temporary  relief.  In  September,  1908,  when  I 
first  began  to  experiment  with  bismuth  paste,  I  decided  to  try  it  on 
this  case.  It  required  only  five  injections  at  intervals  of  four  days  to 
produce  cessation  of  the  discharge,  and  now,  after  two  years,  no  re- 
currence has  taken  place.     Result:   cure. 

Case  5.  Pyorrhea  Alveolaris  (Severe  Case,  Local  Cause). — J.  R.  B., 
aged  41,  salesman.  For  more  than  a  year  has  had  a  profuse  pus  dis- 
charge from  the  deep  pockets  of  nearly  all  his  badly  neglected  and 
many  decayed  teeth.  Abundance  of  salivary  and  seruminal  deposits 
were  present.  No  treatment  had  been  applied  up  to  December,  1908, 
when  I  made  the  first  injection  of  bismuth  paste.  A  few  days  after 
this  injection  the  deposits  were  removed,  and  injections  repeated  at 
three  to  four  days'  intervals  for  a  period  of  six  weeks.  Improvement 
followed,  but  patient  had  to  leave  the  city  for  two  months.  Upon  his 
return  the  treatment  was  resumed,  and  after  four  months'  treatment 
the  discharge  ceased.  Decayed  teeth  were  then  filled,  and  up  to  this 
date  not  the  slightest  sign  of  recurrence  has  manifested  itself.  Re- 
sult:  cure. 


224       BISMUTH  PASTE  IN  CHRONIC  SUPPURATIONS. 

Case  2.  Double  Alveolar  Fistula. — Ed.  M.,  aged  34,  merchant.  Pre- 
sented himself  in  November,  1908,  with  two  fistulous  openings  oppo- 
site the  roots  of  the  second  upper  molar.  One  opening  was  on  the 
lingual  and  the  other  on  the  buccal  surface.  All  the  teeth  on  that  side 
were  sound  and  vital.  An  injection  of  bismuth  paste  was  made,  and 
the  patient  returned  next  day  with  severe  pain  in  the  right  first  upper 
molar.  I  exposed  the  pulp  in  this  tooth,  but  found  no  pus.  This  indi- 
cated that  the  sinus  did  not  originate  in  the  first  molar.  A  radiograph 
was  taken,  which  clearly  showed  the  tract  of  the  sinus  leading  into  the 
region  of  the  root  of  this  tooth,  but  not  communicating  with  it.     The 


Pig.  81.  Cyst  of  lower  maxilla  filled  with  bismuth  paste.  A,  bismuth  paste  ; 
B,   light  zone  of  granulations  ;  C,   gold  crowns. 

tooth  was  filled  and  injections  continued.  After  four  injections  the 
buccal  fistula  closed,  and  two  more  injections  sufficed  to  close  the 
lingual.  Six  months  later  the  lingual  fistula  reopened,  but  after  two 
injections  of  paste  closed  again,  and  no  recurrence  has  taken  place 
since.     Result:   cure. 

Cysts  and  Sinuses  Following  Fractures. 

Another  class  of  cases  which  sometimes  come  under 
the  care  of  the  dentist  are  sinnses  of  the  jaws  due  to  frac- 
tures or  cysts.     I  desire  to  illustrate  a  case  in  radiograph 


BISMUTH   PASTE  IN  DENTISTRY.  225 

(Fig.  8]),  which  shows  a  cyst  in  the  lower  maxilla.  The 
cyst  was  opened  and  the  cavity  filled  with  bismuth  paste, 
and  the  picture  most  graphically  illustrates  the  contour 
of  the  bony  cyst.  Surrounding-  the  borders  of  the  injected 
paste  we  note  a  light  zone,  which  represents  the  granula- 
tions lining  this  cavity.  The  darker  margin  of  this  light 
zone  shows  the  ostitis  which  marks  its  boundaries. 

The  value  of  this  diagnostic  method  must  appeal  to 
those  who  have  had  difficulty  in  estimating  the  size  of 
these  bone  cysts. 

Frequently  the  radiograph  will  show  a  sequestrum  in 
the  jaw,  which,  after  removal,  leaves  a  cavity  which 
should  be  injected  for  therapeutic  purposes. 

While  the  introduction  of  the  bismuth  paste  into  den- 
tistry is  of  recent  origin,  sufficient  reports  from  some  of 
the  most  prominent  dental  surgeons  in  the  country  indi- 
cate that  its  use  also  in  dentistry  will  find  many  advo- 
cates. 


REFERENCES. 


Adami,  22 

Babcock,  147 

Baer,  50,  51,  54,  5S 

Beck,  Carl,  31,  78,  115,  174 

Beck,  Emil  G.,  46,  49,  51,  188,  199 

Beck,  Joseph  C,  51,  199 

Beck,  Rudolph,  171,  218,  221,  223 

Bennecke,  183 

Bergeret,  188 

Biesalsky,  21 

Blanchard,  47,  49,  51,  54 

Bogardus,  51 

Bonney,  56 

Bouvier,  154 

Boyer,  51,  118 

Bohme,  183,  184,  185 

Brauer,  114 

Bruns,  45 

Calot,  61,  154,  157 
Collishon,  185 
Coyon,  168 
Cuthbertson,  51,  133 

Dahl,  38 

Dollinger,  51,  63 
Don,  51,  54 
Dunning,  54 
Dupuytren,  154 

Eggenberger,  193 
Ely,  51 

Pavill,  143 
Fiesenger,  168 
Follin,  155 
Forlanini,  114 
Friedrich,  61 

Gangolphe,  158 
Gehrmann,  57,  190 
Gibney,  88 
Gutig,  186 

Halsted,  55 
Hansel,  61 
Harnack,  188 
Hartford,  142 
Hefter,  184 


Heitz,  51,  118 
Her  rick,  56 
Herzog,  57 
Hines,  51 
Hoffa,  63 
Hoffman,  183 

Kadjan,  136 
Kaufmann,  193 
Kelly,  131 
Killian,  209 
Koch,  60 
Kocher,  88,  182 

Konig,   61,  80,   82,  88,   96,   97,  106, 
155 

Lannelongue,  155 
Larrey,  154 
Lexer,  81 

Maasen,  187 
Matsuoka,  194 
Mayo,  49,  112,  113,  136 
McGuire,  49,  136 
Moore,  144 
Morens,  118 
Murphy,  112,  114,  144 
Miihlig,  182 
Miiller,  61 

Nemanoff,  51,  136 
Novak,  186 

Ochsner..  49,  51,  123,  136 

Pennington,  51,  126 
Peterson,  1S2 

Reich,  193 

Ridlon,  47,  49,  51,  54 
Robitschek,  51 
Rosenbach,  51 
Routenberg,  185 
Ryerson,  54 

Sandor,  51 
Schober,  51 
Schuler,  181 
Steinmann.  51 
Stern,  51 


227 


228 


Taylor,  97 


Verity,  190,  193 
Vidakovich,  51,  137 
Von  Bardeleben,  181 


REFERENCES. 


Wilms,  193 
Wood,  188 

Zollinger,  51 


INDEX. 


Abdominal  fistula,  post-operative, 
of  pyogenic  origin,  117 
operation,    post-operative    sinus 
following,  110 
Abscess  as  complication  of  spon- 
dylitis, 62 
at  hip,  originating  in  sacrum,  38 
bilateral  psoas,  66 
cavity,    bismuth    subnitrate    in, 
188 
sinus  formed  by,  65 
cause  of,  24 
chronic  alveolar,  221 
cold,  bismuth  paste  in  treatment 
of,  154 
cause  of,  25,  155 
danger  of  incising,  26 
hip  joint,  162 
psoas,  161 

table  of,  cases  treated,  165 
treatment,  157,  160 
kidney,  sinus  after,  123 
lung,  137,  146 
bismuth    paste    in    aftertreat- 

ment  of,  135 
multilocular,  condition  of,  151 
mistaken  for  rectal  fistula,  124 
psoas,  cause  of,  25 
subphrenic,    following  appendi- 
citis, 40 
table  of  cold,  cases  treated,  165 
Accessory  sinus,  bismuth  paste  in, 
199 
sinuses,    suppuration     of     nose 
and,  204 
Action  of  bismuth  paste  as  modi- 
fying substance,  167 
Acute  nitrate  poisoning,  181 
Adenitis,  tuberculous,   spondylitis 

mistaken  for,  25 
Aid  in  diagnosis,  20 

in  treatment,  20 
Alveolar  abscess,  chronic,  221 

fistula,  chronic,  221 
Anatomical  diagnosis,  28 

failure  of  bismuth  paste  due  to 

incorrect,  125 
stereoradiograph  as  guide  in,  31 , 
146 


Ankle  joint,   wrist  affected   same 
as,  106 
tuberculosis  of,  103 
Antitoxins  as  protective  factor,  22 
Antrum     of     Highmore,     chronic 
suppuration  of,  202 
injection  of,  205 
technic  in,  211 
Appendicitis,    subphrenic    abscess 

following,  40 
Application    after    cautery   of   in- 
ferior turbinated  body,  214 
in  septal  ulcer,  214 
of  bismuth  paste,  29,  53 
rules  for,  52 
Arthritis,  pyogenic,  69,  79 

tuberculous,  69,  82 
Aspiration  and  injection  of  modi- 
fying fluids,  158 
Atrophic  rhinitis,  202 
Avoidance    of    bismuth    intoxica- 
tion, 195 

B 
Bacteriolysins    as    protective    fac- 
tor, 22 
Bilateral   knee  joint  tuberculosis, 
98 
psoas  abscess,  66 
Bismuth  intoxication,  193 

avoidance  of,  195 
Bismuth  paste,  action  of,  as  mod- 
ifying substance,  159,  167 
application  of,  29,  53 
as  diagnostic  aid,  135 
as  therapeutic  agent,  135 
bronchial  tree  injected  with,  153 
causes  of  failure  of,  171,  172 
chemotactic  action  of,  58,  168 
contraindication  of,  172 
discovery  of  curative  effects  cf, 

44 
displaces  probe,  130 
effect  of,  on  tubercle  bacilli,  56 
failure   of,   due   to   faulty  tech- 
nic, 125 
due    to    incorrect    anatomical 
diagnosis.  125 
first  test  of,  44 
formula  No.  1  of,  2S 


22?) 


230 


INDEX. 


Bismuth  paste— cont'd, 
formula  No.  2  of,  44 
in  accessory  sinus,  199 
in    aftertreatment    of    lung    ab- 
scess, 135 
in    chronic    disease    of    mastoid 

process,  199 
in   chronic   suppurative   disease 

of  ears,  199 
in   chronic   suppurative   disease 

of  nose,  199 
in  dentistry,  171,  218 
in  disease  of  ear,  215 
in   disease   of   mastoid   process, 

215 
in  empyema,  46 
in  fecal  fistula,  132 
in  nose  for  other  disease  than 

sinus,  214 
in  pyorrhea  alveolaris,  171 
in  sinus  of  ear,  171 
in  sinus  of  mouth,  171 
in  sinus  of  nose,  171 
in  treatment  of  cold  abscess,  154 
in  veterinary  cases,  171 
limitation  of,  171 

in  peritoneal  cavity,  115 
mechanical  acticn  of,  58 
not  cause  of  nitrate  poisoning, 

189 
preparation  of,  28 
reliability  of,  33 
reveals     diagnostic     errors,    35, 

124 
rules  for  application  of,  52 
therapeutic  action  of,  54 
therapeutic  effects  of,  44 
treatment,  cases  suitable  for,  53 
of  empyema,  135 
palliative  method  of,  205 
radical  method  of,  209 
Bismuth  poisoning,  180 
due  to  dusting  power,  182 
prevention  of,  180,  196,  198 
symptoms  of,  181 
Bismuth   subnitrate,  effect  of,  on 

animals,  184 
effect  of  x-rays  on,  59 
in  abscess  cavities,  188 
in  empyema,  188 
in  sinus,  188 

nitrite  poisoning  due  to,  183, 186 
nontoxicity  of,  181 
Bismuth  treatment,  indication  for, 

177 
Bone  disease  of  foot,  sinus  from, 

102 
formation,  framework  for,  203 


Bronchial  tree  injected  with  bis- 
muth paste,  153 


Calot's  mixture,  formula  for,  158 
Calculi,  cystic  kidney  with,  119 
Cases  cited — abscess  at  hip,  orig- 
inating in  sacrum,  38 

bilateral    knee   joint   tuberculo- 
sis, 98 

bilateral  psoas  abscess  without 
destruction  of  vertebrae,  66 

bismuth  paste  not  cause  of  ni- 
trite poisoning,  189 

bismuth  poisoning  due  to  dust- 
ing powder,  182,  183 

chronic    alveolar    abscess    with 
fistulous  tract,  222 

cold  hip  joint  abscess,  162 

cold  psoas  abscess,  161 

cystic  kidney  with  calculi,  119 

double  alveolar  fistula,  223 

effect  of  bismuth   paste   on  tu- 
bercle bacilli,  56 

empyema,  135,  142 

empyema  after  Estlander  oper- 
ation, 177 

empyema  of  infant,  144 

empyema    of    spontaneous    rup- 
ture, 140 

fecal  fistula,  132 

first  test  of  bismuth  paste,  44 

foreign   body    cause    of    failure, 
173,  174 

hip  joint  disease,  sixteen  years' 
duration,  89 

hip  joint  disease,  six  years'  du- 
ration, 91 

knee  joint  tuberculosis,  100,  102 

large  sequestrum  of  ulna,  174 

lung  abscess,  146 

mild  pyorrhea  alveolaris,  223 

nephrectomy,  121 

nitrite  poisoning  due  to  bismuth 
subnitrate,  183,  186 

nontubercular    osteomyelitis    of 
humerus,  71 

osteomyelitis    of   femur   treated 
for  hip  joint  disease,  37 

post-operative  abdominal  fistula 
of  pyogenic  origin,  117 

prevention    of   bismuth    poison- 
ing, 196 

pyorrhea  alveolaris,  219 

rectal  fistula,  124 

rectal  fistula  originating  in  the 
pelvis,  129 

re-expansion  of  lung,  138 


1NDKX. 


231 


Cases  cited — cont'd. 

severe  pyorrhea  alveolaris,  223 

simple  empyema,  140 

sinus  following  tuberculous 
peritonitis,  111,  115 

sinus  from  dermoid  cyst,  128 

sinus  from  pyogenic  osteomye- 
litis of  the  femur,  95 

spondylitis  of  tenth  dorsal,  with 
supraclavicular  and  lumbar 
sinuses,  63 

spondylitis,  sixteen  years'  dura- 
tion, 64 

subphrenic  abscess  following 
appendicitis,  40 

tuberculosis  in  os  calcis,  105 

tuberculosis  of  elbow  with  mul- 
tiple cold  abscess,  163 

tuberculosis  of  kidney,  122 

tuberculosis  of  sacrum  mis- 
taken for  hip  joint  disease, 
39 

tuberculosis  of  sternum  mis- 
taken for  tuberculosis  of 
ribs,  109 

tuberculous  ankle,  ten  years' 
duration,  103 

tuberculous  kidney,  119 

tuberculous  peritonitis,  115 

unsuspected  renal  sinus,  41 

value  of  radiograph  in  diagno- 
sis, 31 
Cases  suitable  for  bismuth  paste 
treatment,  53 

treated,  table  of,  47,  48,  49,  50, 
51 
Cause  of  abscess,  24 

of  cold  abscess,  25,  155 

of  empyema,  24 

of  failure,  faulty  technic,  176 

of  failure,  foreign  body,  173, 175 

of  failure,  sequestrum,  174 

of  failure,  unexplained,  177 

of  failure  of  bismuth  paste,  171, 
172 

of  fistula,  26,  130 

of  methemoglobinemia,  187 

of  psoas  abscess,  25 

of  sinus,  24,  26 

of  sequestrum,  71 

of  suppuration,  24 
Cautery,  application  after,  of  in- 
ferior turbinated  body,  214 
Cavity  after   Estlander  operation, 

140 
Chemotactic     action     of    bismuth 

paste,  58,  168 
Chest  cases,  technic  in,  137 

x-ray  in,  137 


Chronic  alveolar  abscess,  221 
fistula,  221 
lacunar  tonsilitis,  202 
suppuration  of  antrum  of  High- 
more,  202 
suppuration  of  middle  ear,  202 
suppurations,  table  of  cases  of, 
about  head  and  neck,  200 
Clinical   course   of  joint  tubercu- 
losis, 84 
Coccyx,  dermoid  cyst  of,  mistaken 

for  rectal  fistula,  128 
Cold    abscess,    bismuth    paste    in 
treatment  of,  154 
cases  treated,  table  of,  165 
cause  of,  25,  155 
danger  of  incising,  26 
treatment  of,  157,  160 
hip  joint  abscess,  162 
psoas  abscess,  161 
Colored  fluids,  unreliability  of,  32 
Contraindication  of  bismuth  paste, 

172 
Curative  effects  of  bismuth  paste, 

discovery  of,  44 
Cyst,  dermoid,  of  coccyx  mistaken 
for  rectal  fistula,  128 
of  sacrum  mistaken  for  rectal 
fistula,  128 
sinus  of  jaw  due  to,  224 
Cystic  kidney  with  calculi,  119 

D 

Deficiency  in  lime  salts,  104 
Deformity      as      complication     of 
spondylitis,  62 
of  spine  in  spondylitis,  64 
Dentistry,    bismuth    paste   in    171, 

218 
Dermoid  cyst  of  coccyx  mistaken 
for  rectal  fistula,  128 
of  sacrum  mistaken   for  rectal 
fistula,  128 
Diagnosis,  aid  in,  20 
anatomical,  28 

failure  of  bismuth  paste  due 
to  incorrect,  125 
stereoradiograph    as    guide    in, 

31,  146 
value  of  radiograph  in,  31 
Diagnostic  aid,  bismuth  paste  as, 
135 
errors,    bismuth    paste    reveals, 
35, 124 
Diffuse  tuberculous  ostitis,  SI 
Discovery    of    curative    effects    of 

bismuth  paste,  44 
Dressing,   post-operative,  in  infe- 
rior turbinectomy,  214 


232 


INDEX. 


Dressing: — cont'd. 

primary,    following    submucous 
resection,  202 
in   radical  mastoid  operation, 

203 
in   simple   mastoid  operation, 
215 
secondary,    in    radical    mastoid 
operation,  203,217 
in   simple  mastoid  operation, 
203,216 
Dusting  powder,  bismuth  poison- 
ing due  to,  182 

E 

Ear,    bismuth    paste    in    chronic 
suppurative  disease  of,  199 
in  disease  of,  215 
in  sinus  of,  171 
chronic  suppuration  of  middle, 

202 
instruments  for,  206 
Effect  of  bismuth  paste  on  tuber- 
cle bacilli,  56 
of    bismuth    subnitrate    on    ani- 
mals, 184 
of  x-rays  on  bismuth  subnitrate, 
59 
on  vaselin,  59 
Elbow  joint,  sinus  from  tubercu- 
losis of,  105 
tuberculosis  of,  163 
Empyema,  135,  136,  137,  142 
after  Estlander  operation,  177 
bismuth  paste  in,  46 

treatment  of,  135 
bismuth  subnitrate  in,  188 
cause  of,  24 
of  infant,  144 

of  spontaneous  rupture,  140 
simple,  140 
tuberculous,  144 
Errors,  bismuth  paste  reveals  di- 
agnostic, 35,  124 
Estlander  operation,  cavity  after, 
140 
empyema  after,  177 
Ethmoidal  labyrinth,  injection  of, 
205 
technic  of,  214 
Ethmoid  suppuration,  202 


Failure,    causes    of,    of    bismuth 

paste,  171,  172 
faulty  technic  cause  of,  176 
foreign  body  cause  of,  173,  174 
of  bismuth  paste  due  to  faulty 

technic,  125 


Failure— cont'd. 

of  bismuth  paste  due  to  incor- 
rect   anatomical    diagnosis, 
125 
sequestrum  cause  of,  174 
unexplained  cause  of,  177 
Faulty    technic    cause    of   failure, 

176 
Fecal  fistula,  132 

bismuth  paste  in,  132 
treatment  of,  133 
Femur,   sinus    from  pyogenic   os- 
teomyelitis of  the,  93 
First  test  of  bismuth  paste,  44 
Fistula  as  complication  of  spon- 
dylitis, 62 
cause  of,  26,  130 
chronic  alveolar,  221 
fecal,  132 

bismuth  paste  in,  132 
treatment  of,  133 
in  horses,  171 
post-operative      abdominal,      of 

pyogenic  origin,  117 
rectal,  124 

abscess  mistaken  for,  124 
dermoid   cyst  of  coccyx  mis- 
taken for,  128 
originating  in  the  pelvis,  129 
technic  in,  126 
Fistulas     sequelae     of     infectious 

processes,  21 
Fluids,  modifying,  aspiration  and 

injection  of,  158 
Foot,  sinus  from  bone  disease  of, 
102 
sinus  from  joint  disease  of,  102 
Foreign  body  cause  of  failure,  173, 

174 
Formula  for  Calot's  mixture,  158 
for  Murphy's  formalin  mixture, 

158 
No.  1  of  bismuth  paste,  28 
No.  2  of  bismuth  paste,  44 
Fracture,  sinus  of  jaw  due  to,  224 
Framework    for    bone    formation, 

203 
Frontal  sinus,  injection  of,  208 
operation,  209 
technic  in,  210 

G 

General   consideration  of  sinuses, 
21 

H 
Head,   table    of    cases   of   chronic 

suppurations  about,  200 
Hemorrhage,    intranasal,   203 


INDEX. 


')*>'> 
£<><> 


Hip,  abscess  at,  originating  in  sa- 
crum, 38 
joint  abscess,  cold,  162 
disease,  89,  91 
mortality  in,  88 
osteomyelitis   mistaken  for, 

37 
sinus  following,  85 
tuberculosis  of  sacrum  mis- 
taken for,  39 
Horses,  fistula  in,  171 
Humerus,  nontubercular  osteomy- 
elitis of,  71 

I 

Incising,  danger  of,  cold  abscess, 

26 
Indication  for  bismuth  treatment, 
177 
for  surgical  treatment,  22 
Infant,  empyema  of,  144 
Infectious    processes,    fistula3    se- 
quelae of,  21 
sinuses  sequela?  of,  21 
Inferior  turbinated  body,  applica- 
tion after  cautery  of,  214 
turbinectomy,        post  -  operative 
dressing  in,  214 
Inflammation,  osteoplastic,  71 
Injection   in    pyorrhea   alveolaris, 
220 
of  antrum  of  Highmore,  205 
of  ethmoidal  labyrinth,  205 
of  frontal  sinus,  208 
of  sphenoidal  sinus,  208 
syringes  for,  28 
technic  of,  28 
Instruments  for  ear,  206 
for  nose,  206 
for  throat,  206 
Intoxication,  bismuth,  193 

avoidance  of,  195 
Intranasal  hemorrhage,  203 
Introduction,  17 


Jaw,  sinus  of,  due  to  cyst,  224 

due  to  fracture,  224 
Joint  disease  of  foot,  sinus  from, 
102 
treatment  of  sinus  following, 
69 
tuberculosis,  clinical  course  of, 
84 

K 

Kidney  abscess,  sinus  after,  123 
cystic,  with  calculi,  119 


Kidney— cont'd. 

operation,    post-operative    sinus 

following,  110 
tuberculosis  of,  122 
tuberculous,  119 
sinus  from,  118 
Knee  joint  disease,  primary  seat 
of,  97 
tuberculosis,  100,  102 

bilateral,  98 
tuberculous,      sinus       resulting 
from,  95 
Kyphus    resulting    from    tubercu- 
lous infection,  62 


Labyrinth,  ethmoid,  technic  cf,  214 
Lacunar  tonsilitis,  chronic,  202 
Lime  salts,  deficiency  in,  104 
Limitation  of  bismuth  paste,  171 

in  peritoneal  cavity,  115 
Limited  value  of  peroxide  of  hy- 
drogen, 33 
Lung  abscess,  137,  146 

bismuth    paste    in    aftertreat- 

ment  of,  135 
multilocular  condition  of,  151 
negative  pressure  for  re-expan- 
sion of,  138 

M 

Mastoid  operation,  primary  dress- 
ing in  radical,  203 
primary    dressing    in    simple, 

215 
secondary  dressing  in  radical, 

203,217 
secondary  dressing  in  simple, 
203, 216 
process,  bismuth  paste  in  chron- 
ic disease  of,  199 
bismuth   paste   in    disease    of, 
215 
Mechanical     action     of     bismuth 

paste,  58 
Mental  influence  as  resisting  fac- 
tor, 23 
Methemoglobinemia,  cause  of,  1S7 
Mixture,  Calct's,  formula  for,  158 
Murphy's  formalin,  formula  for, 
158 
Modifying    fluids,    aspiration    and 
injection  of,  15S 
substance,     action     of     bismuth 
paste  as,  159, 167 
Mortality  in  hip  joint  disease,  8S 
Mouth,  bismuth  paste  in  sinus  of. 
171 


234 


INDEX. 


Multilbcular  condition  of  lung  ab- 
scess,~151 

Murphy's  formalin  mixture,  for- 
mula for,  158 

N 

Neck,    table    of    cases    of    chronic 

suppurations  about,  200 
Negative    pressure    for    re-expan- 
sion of  lung,  138 
Nephrectomy,  121 
Nitrite  poisoning,  acute,  181 

bismuth  paste  not  cause  of,  189 
due  to  bismuth  subnitrate,  183, 

186 
treatment  of,  187 
Nontoxicity  of  bismuth  subnitrate, 

181 
Nontubercular      osteomyelitis     of 

humerus,  71 
Nontuberculous   osteomyelitis,   69, 

93 
Nose,    bismuth    paste    in    chronic 
suppurative  disease  of,  199 
in,  for  other  disease  than  si- 
nus, 214 
in  sinus  of,  171 
instruments  for,  206 
suppuration    of,    and    accessory 
sinuses,  204 

O 

Operation,    empyema     after     Est- 
lander,  177 
Estlander,  cavity  after,  140 
frontal  sinus,  209 
post-operative    sinus    following 
abdominal,  110 
following  kidney,  110 
radical  mastoid,  primary  dress- 
ing in,  203 
secondary  dressing  in,  203,  217 
simple  mastoid,  primary  dress- 
ing in,  215 
secondary  dressing  in,  203,  216 
Opsonins  as  protective  factor,  22 
Os  calcis,  tuberculosis  in,  105 
Osteomyelitis    mistaken    for     hip 
joint  disease,  37 
nontubercular,  of  humerus,  71 
nontuberculous,  69,  93 
pyogenic,  69 

sinus  from,  of  the  femur,  93 
treatment  of  sinus  following,  CO 
tuberculous,  69,  79 
Osteoplastic  inflammation,  71 
Ostitis,  diffuse  tuberculous,  81 


Otitis     externa     eczematosa,     203, 
215 
media,  suppurative,  215 


Palliative  method  of  bismuth  paste 

treatment,  205 
Paralysis  as  complication  of  spon- 
dylitis, 62 
Pelvis,  rectal  fistula  originating  in 

the,  129 
Peritoneal     cavity,     limitation    of 

bismuth  paste  in,  115 
Peritonitis,  tuberculous,  115 
primary  source  of,  113 
sinus  following,  110,  115 
surgical  treatment  in,  114 
Peroxide     of     hydrogen,     limited 

value  of,  33 
Phagocytosis  as  protective  factor, 

22 
Poisoning,  acute  nitrite,  181 
bismuth,  180 

due  to  dusting  powder,  182 
prevention  of,  180,  196,  198 
symptoms  cf,  181 
nitrite,  bismuth  paste  not  cause 
of,  189 
due  to  bismuth  subnitrate,  183, 

186 
treatment  of,  187 
Post-operative    abdominal    fistula 
of  pyogenic  origin,  117 
dressing    in    inferior    turbinec- 

tomy,  214 
sinus  following  abdominal  oper- 
ation, 110 
kidney  operation,  110 
Powder,  dusting,  bismuth  poison- 
ing due  to,  182 
Preparation  cf  bismuth  paste,  28 
Prevention  of  bismuth  poisoning, 

180,  196,  198 
Primary   dressing  following  sub- 
mucous resection,  202 
in   radical  mastoid  operation, 

203 
in   simple   mastoid  operation, 
215 
seat  of  knee  joint  disease,  97 
source  of  tuberculous  peritoni- 
tis, 113 
synovial  tuberculosis,  80 
Probe,    bismuth    paste    displaces, 

130 
Protective  factor,  antitoxins  as,  22 
bacteriolysins  as,  22 
opsonins  as,  22 
phagocytosis  as,  22 


INDEX. 


90 


>•) 


Psoas  abscess,  cause  of,  25 

cold,  161 
Pyogenic  arthritis,  69,  79 

osteomyelitis,  69 

of  the  femur,  sinus  from,  93 
Pyorrhea  alveolaris,  219 

bismuth  paste  in,  171 

injections  in,  220 

R 

Radical  mastoid  operation,  prima- 
ry dressing  in,  203 
secondary  dressing  in,  203,  217 
method  of  bismuth  paste  treat- 
ment, 209 
Radiographs,  stereoscopic,  in  ana- 
tomical diagnosis,  31 
Rectal  fistula,  124 

abscess  mistaken  for,  124 
dermoid  cyst  of  coccyx  mistaken 

for,  128 
originating  in  the  pelvis,  129 
technic  in,  126 
Re-expansion    of    lung,    negative 

pressure  for,  138 
Reliability  of  bismuth  paste,  33 
Renal  sinus,  unsuspected,  41 
Resection,    primary    dressing   fol- 
lowing submucous,  202 
Resisting  factor,  mental  influence 

as,  23 
Rhinitis,  atrophic,  202 
Ribs,  sinus  from  tuberculous,  107 
tuberculosis    of    sternum    mis- 
taken   for    tuberculosis    of, 
109 
Rice  bodies,  82 
Rules   for  application  of  bismuth 

paste,  52 
Rupture,    spontaneous,    empyema 
of,  140 


Sacrum,  abscess  at  hip  originating 
in,  38 
tuberculosis  of,  mistaken  for  hip 
joint  disease,  39 
Secondary     dressing     in     radical 
mastoid  operation,  203,  217 
in  simple  mastoid  operation,  203, 
216 
Septal  ulcer,  application  in,  214 
Sequestrum,  cause  of,  71 
cause  of  failure,  174 
of  ulna,  174 
tuberculous,  81 
Simple  empyema,  140 
mastoid       operation,       primary 
dressing  in,  215 


Simple;  mastoid  operation — cont'd, 
secondary  dressing  In,  203, 216 

Sinus,  accessory,  bismuth  paste  in, 
199 
after  kidney  abscess,  123 
bismuth  paste  in  nose  for  other 

disease  than,  214 
bismuth  subnitrate  in,  188 
cause  of,  24,  26 
due  to  spondylitis,  treatment  of, 

60 
following  hip  joint  disease,  69 
following    joint    disease,    *reat- 

ment  of,  69 
following    osteomyelitis,    treat- 
ment of,  69 
following  tuberculous   peritoni- 
tis, 110,  115 
formed    by    contraction    of    ab- 
scess cavity,  65 
from  bone  disease  of  foot,  102 
from  joint  disease  of  foot,  102 
from  pyogenic  osteomyelitis  of 

the  femur,  93 
from  tuberculosis  of  elbow  joint, 

105 
from  tuberculous  kidney,  118 
from  tuberculous  ribs,  107 
from  tuberculous  sternum,  107 
frontal,  injection  of,  208 

technic  in,  210 
in    spondylitis    of  tenth    dorsal, 

63 
of  ear,  bismuth  paste  in,  171 
of  jaw  due  to  cyst,  224 

due  to  fracture,  224 
of  mouth,  bismuth  paste  in,  171 
of  nose,  bismuth  paste  in,  171 
post-operative,     following      ab- 
dominal operation,  110 
following     kidney     operation, 
110 
resulting  from  tuberculous  knee 

joint,  95 
sphenoidal,  injection  of,  20S 

technic  of,  214 
unsuspected  renal,  41 
Sinuses  from  tuberculous  coxitis, 
table  of  cases  of,  86 
general  consideration  of,  21 
sequelae  of  infectious  processes, 
21 
Sphenoidal  sinus,  injection  of,  20S 

technic  of,  214 
Spine,   deformity  of,  in   spondyli- 
tis, 64 
Spondylitis  a  tuberculosis,  60 
abscess  as  complication  of,  62 
deformity  as  complication  of,  62 


236 


INDEX. 


Spondylitis — cont'd. 

deformity  of  spine  in,  64 
fistula  as  complication  of,  62 
mistaken  for  tuberculous  adeni- 
tis, 25 
of  tenth  dorsal,  sinus  in,  63 
paralysis  as  complication  of,  62 
treatment  of  sinus  due  to,  60 
Spontaneous  rupture,  empyema  of, 

140 
Stereoradiograph  as  guide  in  ana- 
tomical diagnosis,  31,  146 
Sternum,  sinus  from  tuberculous, 
107 
tuberculosis  of,  mistaken  for  tu- 
berculosis of  ribs,  109 
Submucous      resection,      primary 

dressing  following,  202 
Subnitrate,  bismuth,  effect  of,  on 
animals,  184 
in  abscess  cavities,  188 
in  empyema,  188 
in  sinus,  188 

nitrite  poisoning  due  to,  183,  186 
nontoxicity  of,  181 
Subphrenic  abscess  following  ap- 
pendicitis, 40 
Suppuration,  cause  of,  24 

chronic,    of    antrum    of    High- 
more,  202 
of  middle  ear,  202 
ethmoid,  202 

of  nose  and  accessory  sinuses, 
204 
Suppurations,     chronic,    table     of 
cases    of,    about    head    and 
neck,  200 
Suppurative  otitis  media,  215 
Surgical  treatment,  indication  fcr, 
22 
in  tuberculous  peritonitis,  114 
Symptoms   of   bismuth   poisoning, 

181 
Syringes  for  injection,  28 


Table  of  cases  of  chronic  suppu- 
rations    about     head     and 
neck,  200 
of  sinuses  from  tuberculous  cox- 
itis, 86 
treated,  47,  48,  49,  50,  51 
of    cold    abscess    cases    treated, 
165 
Technic,  faulty,  cause  of  failure, 
176 
failure  of  bismuth  paste  due  to 

faulty,  125 
in  antrum  of  Highmore,  211 


Technic — cont'd, 
in  chest  cases,  137 
in  frontal  sinus,  210 
in  rectal  fistula,  126 
of  ethmoid  labyrinth,  214 
of  injections,  28 
of  sphenoid  sinus,  214 
of  therapeutic  application,  44 
Therapeutic     action     of     bismuth 
paste,  54 
agent,  bismuth  paste  as,  135 
application,  technic  of,  44 
effects  of  bismuth  paste,  44 
Throat,  instruments  for,  206  . 
Tonsilitis,  chronic  lacunar,  202 
Treatment,  aid  in,  20 

bismuth  paste,  of  empyema,  135 
of  lung  abscess,  135 
palliative  method  of,  205 
radical  method  of,  209 
of  cold  abscess,  157,  160 
bismuth  paste  in,  154 
of  fecal  fistula,  133 
of  nitrite  poisoning,  187 
of  sinus  due  to  spondylitis,  60 
of  sinus  following  joint  disease, 

69 
of  sinus  following  osteomyelitis, 
69 
Tubercle  bacilli,  effect  of  bismuth 

paste  on,  56 
Tuberculosis,  bilateral  knee  joint, 
98 
in  os  calcis,  105 
of  ankle,  103 
of  elbow,  163 

of  elbow  joint,  sinus  from,  105 
of  kidney,  122 
of  ribs,  tuberculosis  of  sternum 

mistaken  for,  109 
of    sacrum    mistaken     for    hip 

joint  disease,  39 
of  sternum  mistaken  for  tuber- 
culosis of  ribs,  109 
primary  synovial,  80 
joint,  clinical  course  of,  84 
knee  joint,  100,  102 
spondylitis  a,  60 
Tuberculous    adenitis,    spondylitis 
mistaken  for,  25 
arthritis,  69,  82 
empyema,  144 
infection,  kyphus  resulting  from, 

62 
kidney,  119 

sinus  from,  118 
knee  joint,  sinus  resulting  from, 

95 
osteomyelitis,  69,  71 


[NDEX. 


2W1 


Tuberculous — cont'd, 
ostitis,  diffuse,  81 
peritonitis,  115 

primary  source  of,  113 
sinus  following,  110,  115 
surgical  treatment  in,  114 
ribs,  sinus  from,  107 
sequestrum,  81 
sternum,  sinus  from,  107 
Turbinectomy,  inferior,  post-oper 
ative  dressing  in,  214 

U 
Ulcer,  septal,  application  in,  214 
Ulna,  sequestrum  of,  174 
Unexplained  cause  of  failure,  177 
Unreliability  of  colored  fluids,  32 
Unsuspected  renal  sinus,  41 


Value  of  radiograph   in  diagnosis, 

31 
Vaselin,  effect  of  x-rays  on,  59 
Veterinary  cases,  bismuth  in,  171 

W 

Wrist     affected     same     as     ankle 
joint,  106 


X 

X-rays,  effect  of,  on  bismuth  sub- 
nitrate,  59 
on  vaselin,  59 
in  chest  cases,  137 


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